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                                      Nebraska Change of Address Request                                                                         FORM

                                                           for Individual Income Tax Only                                                        22A
  Social Security Number               

 Nebraska ID Number 

     Previous Name and Mailing Address                                  New Name and Mailing Address
 Your First Name and Initial                         Last Name          Your First Name and Initial                        Last Name

  If a Joint Return, Spouse’s First Name and Initial Last Name          If a Joint Return, Spouse’s First Name and Initial Last Name

  Mailing Address (Number and Street or PO Box)                         Mailing Address (Number and Street or PO Box)

  City, Town, or Post Office                         State     Zip Code City, Town, or Post Office                         State                 Zip Code

     Under penalties of law, I declare that I have examined this request, and to the best of my knowledge and belief, it is correct and complete.

 sign
     Duly Authorized Signature                                                                      Date                                         Phone Number
 here
     Email Address

                                                      You may fax this request to 402-471-5927, or
                             mail to: Nebraska Department of Revenue, PO Box 98911, Lincoln, NE 68509-8911.
                                                           Please keep a copy for your records.
                                                                                                                                                 8-548-1996 Rev. 11-2016
                                                                                                                                                 8-548-1996 Rev.  9-2014