FORM
                                                        Nebraska Change Request
                                                Use Form 22A for individual income tax name/address changes.                                                    22
1   Nebraska ID Number                          3       County of Business Location in Nebraska    Please Do Not Write in This Space
                                                        (if applicable)
  2 Federal Employer ID Number                  4       Business Classification Code                       PRINT FORM                     RESET FORM

                       Name and Location Address                                                                    Name and Mailing Address
  Names on your Certificate, License, or Permit                                              Names on your Certificate, License, or Permit

  Address (Number and Street)                                                                Street or Other Mailing Address

  City                                     State                       Zip Code              City                                         State                 Zip Code

5   Check All Tax Programs Affected by Request:
       Sales Tax (01)                      Fiduciary Income Tax (23)                          Wholesale Cigarette Dealer (47)             Litter Fee (67)
       Retailer’s Use Tax (02)             Corporation Income Tax (24)                        Tobacco Products (56)                       Lodging Tax (68)
       Use Tax (04)                        Financial Institution Tax (24)                     Unstamped Cigarette Transporter (63)        Other
       Prepaid Wireless Surcharge (19)     Partnership Income Tax (25)                        Waste Reduction & Recycling Fee (64)
       Income Tax Withholding (21)         Severance and Conservation Tax (45)                Tire Fee (66)
                                   Indicate Type of Action Requested by Checking Appropriate Boxes Below
If you have a change in the ownership of your business, or have obtained a different federal employer ID number, you must cancel your certificates, 
       licenses, and permits. The new entity must file a Nebraska Tax Application, Form 20, to obtain its own certificates, licenses, and permits.
                         Date of Last Transaction                                                 Location of Records
6      Cancellation
                         Month _______ Day ________ Year _______ 
                         Date of Reinstatement                           Year the Account was     Location of Records
7      Reinstatement                                                   Cancelled
                         Month _____ Day _____ Year _____ 
                          Returns are Presently Filed:                                            Request Permission to File Future Returns:
8      Change in                   Monthly              Quarterly               Annually           Monthly                    Quarterly         Annually
       Filing Frequency
                         Average Annual Tax Liability                    Average is Based on:                         Number of Months Used to Compute Average
                        $                                                       Estimate          Reported Amounts
9      Change in Name and Address
If you are changing the names or addresses on your certificates, licenses, or permits (for example, due to a name change, relocation, or 
correction, and not from a change in ownership or federal ID number), please complete the following information.
           New Name and Location Address of Business                                                       New Name and Mailing Address
  Name Doing Business As (DBA)                                                               Name

  Business Legal Name 

  Business Address (Number and Street)                                                       Street or Other Mailing Address

  City                                     State                       Zip Code              City                                  State                        Zip Code

10  Is this a Nebraska location within the city limits? 
                                                                                           11       Change in Officers, Members, or Partners (Attach list. See instructions.)
       (1) Yes                     (2)     No
12  Reason for Request

                    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
            Signature of Owner, Partner, Member, Corporate Officer, or               Title                                    Date              Phone Number
here        Authorized Individual

           Email Address
    You may fax this request to 402-471-5927, or mail it to: Nebraska Department of Revenue, PO Box 98903, Lincoln, NE 68509-8903.
                                                revenue.nebraska.gov, 800-742-7474 (NE and IA), 402-471-5729
                                                                                                                                                                7-104-1975 Rev. 9-2021
                                                                       Retain a copy for your records.                                          Supersedes 7-104-1975 Rev. 2-2021

                                                       Instructions
Who Must File. A Form 22 should be filed by any taxpayer who:
 •      Has a name or address change;
 •      Needs to correct, cancel, reinstate, or change a Nebraska tax certificate, license, or permit; 
 •      Needs to change the filing frequency for sales and use tax, tire fee, lodging tax, or income tax withholding returns; or
 •      Needs to report a change in officers, members, or partners of the business or organization. 
One request may be used to correct, cancel, or change more than one certificate, license, or permit held by the taxpayer for the 
tax programs listed, provided the Nebraska ID number is the same. Nebraska Change of Address Request for Individual Income 
Tax Only, Form 22A, should be used for individual income tax name and address changes.
When and Where to File. Mail to the Nebraska Department of Revenue, PO Box 98903, Lincoln, NE 68509-8903, or fax 
to 402-471-5927, prior to the change.
Permanently Closing the Business. Form 22 should be filed to cancel one or more of the tax programs listed in line 5. 
You are required to file all tax returns for tax periods through the date of your last transaction, or the last wage payment made. 
This date is entered on line 6.
Employers who cancel their income tax withholding account should, within 30 days after discontinuing business, file a final 
Nebraska Reconciliation of Income Tax Withheld, Form W-3N, and attach the state copy of each           Wage and Tax Statement, 
Federal Form W-2, issued to each employee.
                                              Specific Instructions
Line 1. Enter the Nebraska ID number that you hold or have previously held. Do not enter your Social Security number.
Line 2. Enter your federal employer ID number, if you hold one. If one has been applied for, enter “Applied For.” If no federal 
employer ID number is held or applied for, enter your Social Security number.
Line 3. Enter the Nebraska county where your business is located. If located outside of Nebraska, enter “none”. See line 9 
instructions if you are changing your location address.
Name and Address. Enter the name and address as last filed with the Nebraska Department of Revenue (DOR) or which is 
printed on your present certificate, license, or permit. If you are changing the name or address, the new name or address should 
be entered in the area immediately following line 9 of this request.
Line 5. Check the tax programs affected by this request. If there is a change in more than one program, check all appropriate boxes.
Line 6. A taxpayer closing a business must request cancellation of the tax program. A taxpayer having a seasonal type of 
business may request cancellation of the tax program for the period in which no business activity is conducted. Returns must 
be filed for all periods ending prior to the date of cancellation.
A change in ownership or type of ownership will require a new certificate, license, or permit. When possible, the 
Nebraska Tax Application, Form 20, used to obtain a new certificate, license, or permit, should accompany or precede 
this request for cancellation.
Line 7. A taxpayer who previously cancelled a tax program may have it reinstated provided no change in the business has 
occurred that would require a new certificate, license, or permit.
Line 8. A taxpayer filing a sales tax, use tax, or tire fee return with a tax liability of $900 to $3,000 annually may request 
a quarterly filing frequency. Those with a tax liability of less than $900 annually may request an annual filing frequency. 
Taxpayers filing a lodging tax return and remitting $99 or less of tax annually may request to file an annual return. Employers 
withholding less than $500 annually in state income tax may request to file an annual return, rather than quarterly returns.
Changes in filing frequency are not effective until the taxpayer receives approval from DOR. The taxpayer must complete and 
file all preidentified returns received for periods prior to the approval.
Line 9. Enter the new name and address. If your new location address is in a different county, enter the county in line 3 for your 
new location. The location address box cannot contain a PO Box Number; it must show the street address. If the taxpayer wants 
a return to be mailed to a preparer or another person, the name and mailing address should be completed to show this change.
Line 11. In order to keep your information current, please provide information on changes in officers, members, or partners, 
of your business or organization. Attach a complete list with the name, street address, email address, title, and Social Security 
number. Also, identify those that need to be removed and the effective date of the changes. 
Line 12. Please provide a detailed explanation of the reason for this request.  If there has been a change in ownership, give the 
name and address of the new owner.  
Signature. This request must be signed by the owner, partner, member, corporate officer, or other individual authorized to 
sign by a power of attorney on file with DOR. 
Email. By entering an email address, the taxpayer acknowledges that DOR may contact the taxpayer by email. The taxpayer 
accepts any risk to confidentiality associated with this method of communication. DOR will send all confidential information 
by secure email or by the State of Nebraska file share system. If you do not wish to be contacted by email, write “Opt Out” on 
the line labeled “email address.”