Form Address Change Individual Income Tax Name and Address Change Form

1A Your Name (first name initial and last name) 1B Your Social Security Number 2A Spouse s Name (first name initial and last name) 2B Spouse s SSN 3A Your Prior Name (if any) 3B Spouse s Prior Name (if any) 4A Old Mailing Address City State and Zip Code 4B New Mailing Address City State and Zip Code 501 682 7691 5A Business Estate or Trust Name 5B Federal Identification Number 6A Old Mailing Address City State and Zip Code 6B New Mailing Address City State and Zip Code 7 New Business Location (if different from mailing address) 7th and Wolfe Streets Room 2300 Address Change (R 3/16/11) ARKANSAS STATE INCOME TAX Change Form Check all that apply: Name Change Address Change Order LWP (Lost Warrant Papers) Remail Check Check all that apply: Partnership Fiduciary FAX COMPLETED FORM TO: Fax: (501) 682 7691 http://www arkansas gov/dfa If Joint Return Spouse s Signature Date Phone Number If Part I Completed If Part II Completed Individual Income Tax Individual Income Tax Account LITTLE ROCK AR 72203 Little Rock Arkansas 72203 3628 MAIL COMPLETED FORM TO: Phone: (501) 682 1100 Please type or print when filling out this form PO BOX 3628 Post Office Box 3628 REVENUE DIVISION SECTION I COMPLETE THIS PART TO CHANGE YOUR INDIVIDUAL NAME AND ADDRESS SECTION II COMPLETE THIS PART TO CHANGE BUSINESS ADDRESS OR LOCATION SECTION III SIGNATURE Signature of Owner Officer or Representative Date Title Phone Number STATE OF ARKANSAS Your Signature Date Phone Number