Form MF-629 (State Form 49089) "Change of Name/Address Form" - Indiana

What Is Form MF-629 (State Form 49089)?

This is a legal form that was released by the Indiana Department of Revenue - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2021;
  • The latest edition provided by the Indiana Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MF-629 (State Form 49089) by clicking the link below or browse more documents and templates provided by the Indiana Department of Revenue.

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Download Form MF-629 (State Form 49089) "Change of Name/Address Form" - Indiana

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MF-629
Indiana Department of Revenue
State Form 49089
Check all that apply:
Change of Name / Address Form
(R6 / 7-21)
Name Change
Do not use this form to report changes in ownership.
Address Change
Location:
Physical
Mailing
Previous Name and/or Address
Taxpayer Name
DBA
Address
City
State
ZIP Code
New Name and/or Address
Taxpayer Name
DBA
Address
City
State
ZIP Code
Please provide all license numbers to which the above change applies.
1. Taxpayer Identification Number (TID): ______________________________
2. Special Fuel License Number: ____________________________________
3. Gasoline Distributor’s License Number: _____________________________
4. Indiana Gasoline Use Tax License Number: __________________________
5. Indiana Aviation Fuel Excise Tax License Number: ____________________
Taxpayer Identification Number (TID): _______________
Date Signed: _______________________________
Signature: ____________________________________
Printed Name: _____________________________
Title: _________________________________________
Telephone Number: _________________________
Email: ________________________________________
For assistance, call (317) 615-2630 or email the Fuel Tax Section at fetax@dor.in.gov.
Please mail the completed form to: Indiana Department of Revenue
Fuel Tax, Bonds and Licensing Section
P.O. Box 6114
Indianapolis, IN 46206-6114
MF-629
Indiana Department of Revenue
State Form 49089
Check all that apply:
Change of Name / Address Form
(R6 / 7-21)
Name Change
Do not use this form to report changes in ownership.
Address Change
Location:
Physical
Mailing
Previous Name and/or Address
Taxpayer Name
DBA
Address
City
State
ZIP Code
New Name and/or Address
Taxpayer Name
DBA
Address
City
State
ZIP Code
Please provide all license numbers to which the above change applies.
1. Taxpayer Identification Number (TID): ______________________________
2. Special Fuel License Number: ____________________________________
3. Gasoline Distributor’s License Number: _____________________________
4. Indiana Gasoline Use Tax License Number: __________________________
5. Indiana Aviation Fuel Excise Tax License Number: ____________________
Taxpayer Identification Number (TID): _______________
Date Signed: _______________________________
Signature: ____________________________________
Printed Name: _____________________________
Title: _________________________________________
Telephone Number: _________________________
Email: ________________________________________
For assistance, call (317) 615-2630 or email the Fuel Tax Section at fetax@dor.in.gov.
Please mail the completed form to: Indiana Department of Revenue
Fuel Tax, Bonds and Licensing Section
P.O. Box 6114
Indianapolis, IN 46206-6114