Form 22 "Nebraska Change Request" - Nebraska

Form 22 is a Nebraska Department of Revenue form also known as the "Nebraska Change Request". The latest edition of the form was released in September 1, 2017 and is available for digital filing.

Download a PDF version of the Form 22 down below or find it on Nebraska Department of Revenue Forms website.

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Nebraska Change Request
Form
22
Use Form 22A for individual income tax name/address changes.
Please Do Not Write in This Space
1 Nebraska ID Number
3 County of Business Location in Nebraska
RESET FORM
PRINT FORM
2 Federal Employer ID Number
4 For Department Use Only
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 _____
Request Permission to File Future Returns:
Average Annual Tax Liability
8
Change in
$
Monthly
Quarterly
Annually
Filing Frequency
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 Nebraska location within the city limits?
(1)
Yes
(2)
No
11 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
here
Signature of Owner, Partner, Member, Corporate Officer, or
Title
Date
Phone Number
Duly 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
Retain a copy for your records.
9-2017
7-104-1975 Rev.
Supersedes 7-104-1975 Rev. 9-2015
Nebraska Change Request
Form
22
Use Form 22A for individual income tax name/address changes.
Please Do Not Write in This Space
1 Nebraska ID Number
3 County of Business Location in Nebraska
RESET FORM
PRINT FORM
2 Federal Employer ID Number
4 For Department Use Only
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 _____
Request Permission to File Future Returns:
Average Annual Tax Liability
8
Change in
$
Monthly
Quarterly
Annually
Filing Frequency
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 Nebraska location within the city limits?
(1)
Yes
(2)
No
11 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
here
Signature of Owner, Partner, Member, Corporate Officer, or
Title
Date
Phone Number
Duly 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
Retain a copy for your records.
9-2017
7-104-1975 Rev.
Supersedes 7-104-1975 Rev. 9-2015
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; or
Needs to change the filing frequency for sales and use tax, tire fee, lodging tax, or income tax withholding returns.
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
by the date 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 which 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 has been applied for, enter your Social Security number.
Line 3. Enter the Nebraska county where your business is located.
Name and Address. Enter the name and address as last filed with the Nebraska Department of Revenue (Department)
or which is printed on your present certificate, license, or permit. A new name and 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 which 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 approval has been received from the Department. The taxpayer must complete
and file all preidentified returns received for periods prior to the approval.
Line 9. Enter the new name and address. 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. Give 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 the Department.
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