Change Of Name Address Form {MF-629}

State Form 49089 (R5 / 2-14) MF-629 Do not use this form to report changes in ownership. Location: Change of Name/Address Form Indiana Department of Revenue Physical Mailing Check all that apply: Name Change Address Change 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): _______________ Signature: ____________________________________ Title: _________________________________________ Email:________________________________________ Date Signed: _______________________________ Printed Name: _____________________________ Telephone Number: _________________________ For assistance, call (317) 615-2625 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 American LegalNet, Inc. www.FormsWorkFlow.com