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MISSOURI DEPARTMENT OF REVENUE
FORM
• P LEASE USE THIS FORM TO MAKE CHANGES IN
TAXATION DIVISION
2796
YOUR REGISTRATION RECORDS
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
(573) 751-2611
TDD (800) 735-2966
• PLEASE PRINT OR TYPE
(REV. 11-2011)
FUEL TAX REGISTRATION CHANGE REQUEST
MISSOURI MOTOR FUEL LICENSE NUMBER
BUSINESS NAME CURRENTLY ON FILE
___ ___ ___ ___ ___
BUSINESS ADDRESS CURRENTLY ON FILE
PLEASE MAKE THE FOLLOWING CHANGE(S) IN MY REGISTRATION RECORDS: (CHECK AND COMPLETE APPROPRIATE ITEMS)
1.
CHANGE BUSINESS NAME TO:
NAME
D/B/A
2.
CHANGE TYPE OF OWNERSHIP TO:
SOLE OWNER
PARTNERSHIP
GOVERNMENT
OTHER
1
2
3
4
MISSOURI CERTIFICATE OF AUTHORITY NUMBER
5
6
MISSOURI CORPORATION
CORPORATION
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
MISSOURI FICTITIOUS NAME NUMBER
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
FICTITIOUS NAME BUSINESSES:
CHANGE OWNER NAME TO: (USE ONLY IF CHANGE RESULTS FROM CHANGE IN TYPE OF OWNERSHIP. IF OWNER
3.
NAME CHANGES DUE TO TRANSFER OR SALE, ETC., A NEW APPLICATION MUST BE COMPLETED)
NEW LEGAL NAME OF OWNER
CURRENT PHONE NUMBER
(__ __ __) __ __ __ – __ __ __ __
OWNER SOCIAL SECURITY NUMBER
BIRTHDATE (MMDDYYYY)
___ ___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
IF SOLE PROPRIETOR:
(ALL INFORMATION IS REQUIRED. ATTACH A
4.
CHANGE OF RESPONSIBLE PERSONS, PARTNERS, OFFICERS, OR MEMBERS:
SUPPLEMENTAL LIST IF NECESSARY.)
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
HOME ADDRESS
CITY
STATE
ZIP CODE
ADD
___ ___ ___ ___ ___
DELETE
BIRTHDATE
SOCIAL SECURITY NUMBER OR FEIN
COUNTY
EFFECTIVE DATE OF CHANGE
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ ___ ___ ___ ___ ___ ___ ___
__ __ / __ __ / __ __ __ __
NAME (LAST, FIRST, MIDDLE INITIAL)
TITLE
HOME ADDRESS
CITY
STATE
ZIP CODE
ADD
___ ___ ___ ___ ___
DELETE
BIRTHDATE
SOCIAL SECURITY NUMBER OR FEIN
COUNTY
EFFECTIVE DATE OF CHANGE
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ ___ ___ ___ ___ ___ ___ ___
__ __ / __ __ / __ __ __ __
5.
CHANGE CONTACT PERSON:
A Power of Attorney, Form 2827, must be submitted for any person(s) listed as a contact if they are not an owner/officer of the company.
REGISTRATION
REPORTING
NAME
TELEPHONE NUMBER
FAX NUMBER
EMAIL
(__ __ __) __ __ __ – __ __ __ __ (__ __ __) __ __ __ – __ __ __ __
REGISTRATION
REPORTING
NAME
TELEPHONE NUMBER
FAX NUMBER
EMAIL
(__ __ __) __ __ __ – __ __ __ __ (__ __ __) __ __ __ – __ __ __ __
6.
CHANGE ADDRESS TO:
PHYSICAL
MAILING
LOCATION OF BOOKS AND RECORDS
STREET ADDRESS
CITY
STATE
ZIP
COUNTY
__ __ __ __ __
7.
ATTACH ORIGINAL RIDER FROM BONDING COMPANY COVERING CHANGE OF NAME AND/OR PHYSICAL ADDRESS
8.
A NEW BOND INDICATING CHANGE OF OWNERSHIP ACCOMPANIED BY NEW APPLICATION
OWNER OR AUTHORIZED PERSON
TITLE
DATE
__ __ / __ __ / __ __ __ __
DOR-2796 (11-2011)