D0-5 Name or Address Change Form Rev. 12-18
KANSAS DEPARTMENT OF REVENUE Division of Taxation
NAME OR ADDRESS CHANGE FORM
800518
Individual
Current Name: ___________________________________________________________________ Current SSN: ______________________
o I am changing my name. (Name return was filed under) __________________________________________________________________ o I am changing my address
_________________________________ _____________________________ _____________________________________________________
Social Security Number
Contact me by Home Phone Number
Old Email Address
_________________________________ _____________________________ _____________________________________________________
Spouse Social Security Number
Contact me by Cell Phone Number
Current Email Address
________________________________________________________________________________________________________________________ New Name (Include spouse's full name if filed jointly)
________________________________________________________________________________________________________________________ New Address (street, city, state and zip code)
________________________________________________________ Signature
______________________ Date
Business
Current Business Name: ________________________________________________________ Current EIN/SSN: ____________________
o I am changing my business name. New Name: __________________________________________________________________________
o I am changing my address:
o Business Mailing Address
o Business Location Address
o I am correcting my EIN:
o o New EIN ___________________
Old EIN _____________________
This change will affect the following tax accounts:
o Retailers' Sales Tax
o Dry Cleaning Surcharge
o Withholding Tax
o Liquor Drink Tax
o Consumers' Compensating Use Tax
o Liquor Enforcement Tax
o Retailers' Compensating Use Tax
o Nonresident Contractor
o Cigarette Vending Machine Permit
o Privilege Tax
o Corporate Income Tax
o Retail Cigarette License
o Tire Excise Tax o Transient Guest Tax o Vehicle Rental Excise Tax o Water Protection/Clean Drinking Water Fee o Charitable Gaming
Mailing Address:
________________________________________________________________________________________________________________________ New Mailing Address (street, county, city, state and zip code)
______________________________ Contact me by Home Phone Number
___________________________________________________________________________________ Old Email Address
______________________________ Contact me by Cell Phone Number
___________________________________________________________________________________ Current Email Address
Location Address: Effective Date (mm/dd/yyyy):___________________________ ______________________________________________________________________________ Old Location Address (street, county, city, state and zip code) ______________________________________________________________________________ New Location Address (street, county, city, state and zip code)
o o Outside City Limits
Inside City Limits
o o Outside City Limits
Inside City Limits
______________________________ Contact me by Home Phone Number
___________________________________________________________________________________ Old Email Address
______________________________ Contact me by Cell Phone Number
___________________________________________________________________________________ Current Email Address
________________________________________ (Signature)
_________________________________________ (Printed Name)
______________________ (Date)
Mail to: KDOR - Taxpayer Assistance Center, PO Box 3506, Topeka KS 66625-3506 or fax to 785-296-2073. If you have questions about the completion of this form, call 785-368-8222.
DO-5 (Rev. 9-19)
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