D0-5 Name or Address Change Form Rev. 12-18
KANSAS DEPARTMENT OF REVENUE
NAME OR ADDRESS CHANGE FORM
800518
Individual
Current Name: Current SSN: _____________________________________________________________________________________________________________
____________________________________
o o
I am changing my name. New Name: ____________________________________________________________________________________________________________________________________ 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 Business Name: _________________________________________________________________________________________________________
o I am changing my DBA name. New DBA Name: _____________________________________________________________________________________________________________________
o I am changing my address:
o Business Mailing Address
o Business Location Address
o I am correcting my EIN:
o New EIN ________________________________
o 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):____________________________________________
o Outside City Limits o Inside City Limits ______________________________________________________________________________________________________________________________
Old Location Address (street, county, city, state and zip code)
o Outside City Limits o Inside City Limits ______________________________________________________________________________________________________________________________
New Location Address (street, county, city, state and zip code)
________________________________________________
Contact me by Home Phone Number
________________________________________________
Contact me by Cell Phone Number
_________________________________________________________________________________________________________________________________________
Old Email Address
________________________________________________________________________________________________________________________________________
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. 10-20)
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