Rev. 7/10 
                                                                                                        CAT CR 
                                                                                                        Request to Cancel/
                          Please do not                                                                 Reactivate Account 
                          use staples. 
CAT account number             FEIN/SSN 

Use only UPPERCASE letters.
Reporting member's name 

       Please cancel my CAT account effective (MM/DD/YY)       //                      // 

 Reason for cancellation: 
       Taxable gross receipts less than $150,000                                Business closed. Date (MM/DD/YY):                               // // 

       Bankruptcy. Case no:                                                     Organizational change. New FEIN: 
                          Sold/merged business. Please provide the following information regarding the company or individual to whom the business was 
       sold or with whom the business merged: 
       
       Name of company/individual 
       
       Address of company/individual
       
  FEIN of company/individual
       
       CAT account no. of company/individual
       
       Effective date of sale/merger (MM/DD/YY)          

       Please reactivate my CAT account effective (MM/DD/YY)                    //        // 
Reason for reactivation:      Gross receipts greater than $150,000                       Other 
*Please note: If reactivating a combined or consolidated taxpayer group, all members that were part of the group on the cancellation 
date will be reactivated. If group members have changed, please complete form CAT  AR (Add/Remove a Member to/from Group). 
SIGN HERE (required) 
I declare under penalty of perjury that I am the taxpayer or the taxpayer’s authorized agent having knowledge of the relevant facts in 
this matter to fi le this request to cancel/reactivate account. 

 Signature Date (MM/DD/YY) 

 Name Title 
Contact person:  The taxpayer will be represented in the matter by the following individual. Please attach a Declaration of Tax 
Representative (Ohio form TBOR 1), which can be found on the department’s Web site at tax.ohio.gov. 
Your fi rst name                                          M.I. Last name

Home address (number and street) 

City                                                                             State         ZIP code 

Telephone                                   Fax 

 Title                                                                          E-mail 

                          Please send this request to Ohio Department of Taxation, Business Tax Division, 
                               P.O. Box 16158, Columbus, OH 43216-6158 or fax to (206) 666-4462.