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MAIL TO: PO BOX 252
REG-C-L STATE OF NEW JERSEY - DIVISION OF REVENUE TRENTON, NJ
(8-05) 08646-0252
REQUEST FOR CHANGE OF REGISTRATION INFORMATION NO FEE REQUIRED
Use this form to report any change in filing status, business activity, or to change your identification information such as identification number,
business and/or trade name, business address, mailing address, etc. DO NOT use this form for a change in ownership or an incorporation of a busi-
ness. A NJ-REG must be completed for these changes.
A. CURRENT INFORMATION (must be completed to process this form)
FEIN ____________________________________________
Name ______________________________________________________________________________________________________________
Address ____________________________________________________________________________________________________________
B. CHANGES TO IDENTIFICATION INFORMATION
FEIN - Reason for change of FEIN ________________________________________
Business Name
(Corporations authorized by the NJ State Treasurer must file a corporate name change amendment, pg. 39)
Trade Name
Business Location: (Do not use P. O. Box for location address) Mailing Name and Address:
Name ____________________________________________________
Street ___________________________________________________
City ____________________________________ State Street ____________________________________________________
City ______________________________________ State
Zip Code
- Zip Code -
(Give 9-digit Zip) (Give 9-digit Zip)
C. Contact Information: Contact Person: __________________________________________ Title: __________________________________
Daytime Phone: ( ) __________ - _______________ E-mail address: _________________________________________
D. IF SEASONAL, CIRCLE MONTHS BUSINESS WILL BE OPEN:
JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC
E. CHANGES IN OWNERSHIP OR CORPORATE OFFICERS
- Name (Last Name, First, MI) - Social Security Number - Home address (Street, City, State, Zip) %
- Indicate new or resigning officer/owner and effective date of change - Title Ownership
F. CHANGES IN FILING STATUS AND BUSINESS ACTIVITY
Proprietorship/Partnership Date Corporate Entities
Business Sold or Discontinued __________________________ Important: Corporate entities may not use this form to dis-
solve, cancel, withdraw, merge, or consolidate. Forms and
Business Incorporated __________________________ Instructions for these changes may be obtained online at
www.state.nj.us/njbgs/ or by calling the Division of Revenue
Owner Deceased __________________________ at (609) 292-9292.
Name and Address of New Owner or Survivor of Merger _____________________________________________________________________
Date Ceased Collecting Sales Tax _________________________ Date Ceased Renting Motor Vehicles ___________________
Date Ceased Paying Wages _________________________ Date Ceased Sale of New Tires/Motor Vehicles____________
List any new State tax for which this business may be eligible: Tax: ____________________________ Effective Date: ___________________
Signature_______________________________________________________ Date________________________________________
Title ___________________________________________________________ Telephone ( ) ___________________________
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