Correct and Change of Responsible Officer Information

If an officer had his/her registered information changed, this form has to be used to report those changes.

Extracted Text for Proper Search

Correct / Change of 
Responsible Of fi cer Information	
This form is available in a PDF ‘ fi llable’ format; however, it cannot be submitted electronically, 
it must be printed, signed and mailed to the address below.
This form can be used to report any changes in the responsible of fi 	
 cers for your business.   Note:  You cannot use this 
form if the Internal Revenue Service has required you to obtain a new Fe\
deral Identi fi cation Number.  A change in Fed-
eral Identi fi cation Number requires a new registration with the Indiana Department Of\
 Revenue. 	
Business Information	
 Federal Identi fi cation Number (FEIN)  Indiana Taxpayer Identi fi cation Number (TID)
Legal Name of the Entity 
Doing Business 
 As Name (DBA)
Street  Address  City   State  Zip Code	
Old Responsible Offi cer Information	
Social Security No.  Last Name, First Name, Middle Initial, Suf fi x  Title     Address  City  State  Zip Code  Effective Date	
New Responsible Of fi cer Information	
Social Security No.  Last Name, First Name, Middle Initial, Suf fi x  Title     Address  City  State  Zip Code   Begin Date
I affi  rm that the changes provided are correct:  
Signature of the Person Submitting Changes:  Phone:
Printed Name of the Person Submitting Changes:  Title: Date:
Note:  This agency is requesting the disclosure of your Social Security \
Number in accordance with IC 4-1-8-1.  
Disclosure is mandatory, this record cannot be processed without it.
Questions regarding the completion of this form may be directed to the I\
ndiana Department of Revenue at 317-233-4015.  
Mail the completed form to:  Indiana Department of Revenue, Tax Administration 
  P.O. Box 6197, Indianapolis, IN  46206-6197	
ROC-1 	State Form 52039 
(R2/ 10-07)	
 start:    /    end:

INSTRUCTIONS	
Correct/Change of Responsible Offi cer Information
NOTICE:  All information, including the supporting documentation, must be provide\
d 
before the form will be considered to be a valid request.
If more space is needed to record your changes, you may attach a separat\
e sheet.
Business Information Section
Please provide the following required information: 1.  Federal (FEIN) and Indiana (TID) Identi fi cation Numbers
2.  Legal names of the entity submitting the change request
3.  DBA (Doing Business As) Name of the entity 	
(if different from the legal name)	
4.  Business mailing address
Old Responsible Of fi cer Information
Complete all applicable columns.  This information is necessary to ensure we identify and 
remove the correct individual.  
Note:  Supporting documentation establishing a separation date must be provid\
ed.   
Documentation may include: Corporate Minutes, Registration Letter, Financial Documents 
showing removal as a signatory of bank account, Af fi davit from another offi  cer; etc...
New Responsible Of fi cer Information
Complete all applicable columns.  This information is necessary to ensure we correctly 
identify and add the new of fi cer.
Note:  Supporting documentation must be provided.  Documentation may include:\
  Cor-
porate Minutes, Financial Documentation showing the addition of individu\
al as Signatory 
of  Bank Account, Affi  davit from another offi  cer; etc...
This change/correction must be submitted and signed by an existing owner\
, partner 
or corporate offi  cer before it will be accepted by the Department.
Note:  The individual submitting this change form request cannot be the person \
to be 
deleted as a responsible of fi cer.