7-104-1975 Rev. 9-2021
Supersedes 7-104-1975 Rev. 2-2021
22
FORM
Use Form 22A for individual income tax name/address changes.
Nebraska Change Request
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
Retain a copy for your records.
Indicate Type of Action Requested by Checking Appropriate Boxes Below
6 Cancellation
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
here
Average Annual Tax Liability
$
Average is Based on:
Estimate Reported Amounts
Number of Months Used to Compute Average
8 Change in
Filing Frequency
7 Reinstatement
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 Mailing AddressNew Name and Location Address of Business
Returns are Presently Filed: Request Permission to File Future Returns:
Monthly Quarterly Annually Monthly Quarterly Annually
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.
Name and Location Address
Name and Mailing Address
5 Check All Tax Programs Affected by Request:
Sales Tax (01)
Retailer’s Use Tax (02)
Use Tax (04)
Prepaid Wireless Surcharge (19)
Income Tax Withholding (21)
Wholesale Cigarette Dealer (47)
Tobacco Products (56)
Unstamped Cigarette Transporter (63)
Waste Reduction & Recycling Fee (64)
Tire Fee (66)
Fiduciary Income Tax (23)
Corporation Income Tax (24)
Financial Institution Tax (24)
Partnership Income Tax (25)
Severance and Conservation Tax (45)
1 Nebraska ID Number 3 County of Business Location in Nebraska
(if applicable)
2 Federal Employer ID Number 4 Business Classification Code
Please Do Not Write in This Space
Names on your Certificate, License, or Permit
Street or Other Mailing Address
City State Zip Code
Names on your Certificate, License, or Permit
Address (Number and Street)
City State Zip Code
Name
Street or Other Mailing Address
City State Zip Code
Name Doing Business As (DBA)
Business Legal Name
Business Address (Number and Street)
City State Zip Code
Signature of Owner, Partner, Member, Corporate Officer, or Title Date Phone Number
Authorized Individual
Litter Fee (67)
Lodging Tax (68)
Other
Date of Last Transaction Location of Records
Month _______ Day ________ Year _______
Date of Reinstatement Location of Records
Month _____ Day _____ Year _____
Year the Account was
Cancelled
10 Is this a Nebraska location within the city limits?
(1) Yes (2) No
12 Reason for Request
Email Address
11 Change in Officers, Members, or Partners (Attach list. See instructions.)
PRINT FORM
RESET FORM
Instructions
Who Must File. A Form 22 should be led by any taxpayer who:
• Has a name or address change;
• Needs to correct, cancel, reinstate, or change a Nebraska tax certicate, license, or permit;
• Needs to change the ling frequency for sales and use tax, tire fee, lodging tax, or income tax withholding returns; or
• Needs to report a change in ocers, members, or partners of the business or organization.
One request may be used to correct, cancel, or change more than one certicate, 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 led to cancel one or more of the tax programs listed in line 5.
You are required to le 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, le a nal
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 led with the Nebraska Department of Revenue (DOR) or which is
printed on your present certicate, 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 aected 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 led for all periods ending prior to the date of cancellation.
A change in ownership or type of ownership will require a new certicate, license, or permit. When possible, the
Nebraska Tax Application, Form 20, used to obtain a new certicate, 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 certicate, license, or permit.
Line 8. A taxpayer ling a sales tax, use tax, or tire fee return with a tax liability of $900 to $3,000 annually may request
a quarterly ling frequency. Those with a tax liability of less than $900 annually may request an annual ling frequency.
Taxpayers ling a lodging tax return and remitting $99 or less of tax annually may request to le an annual return. Employers
withholding less than $500 annually in state income tax may request to le an annual return, rather than quarterly returns.
Changes in ling frequency are not eective until the taxpayer receives approval from DOR. The taxpayer must complete and
le all preidentied returns received for periods prior to the approval.
Line 9. Enter the new name and address. If your new location address is in a dierent 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 ocers, 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 eective 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 ocer, or other individual authorized to
sign by a power of attorney on le 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 condentiality associated with this method of communication. DOR will send all condential information
by secure email or by the State of Nebraska le share system. If you do not wish to be contacted by email, write “Opt Out” on
the line labeled “email address.”
