Form 22A Fillable Nebraska Change Request for Individual Income Tax Use Only (9/2014)
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

City Town or Post Office State Zip Code City Town or Post Office State Zip Code If a Joint Return Spouse s First Name and Initial Last Name If a Joint Return Spouse s First Name and Initial Last Name Mailing Address (Number and Street or PO Box) Mailing Address (Number and Street or PO Box) Nebraska ID Number Previous Name and Mailing Address New Name and Mailing Address Social Security Number Your First Name and Initial Last Name Your First Name and Initial Last Name 8 548 1996 Rev 10 2010 8 548 1996 Rev 9 2014 Duly Authorized Signature Date Phone Number Email Address for Individual Income Tax Only mail to: Nebraska Department of Revenue PO Box 98911 Lincoln NE 68509 8911 Nebraska Change of Address Request Please keep a copy for your records 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 You may fax this request to 402 471 5927 or