This form is used to notify the Louisiana Department of Revenue of changes to an individual's name, address, or filing status. The taxpayer checks the boxes indicating what has changed (name, address, filing status), provides their new and old names and addresses as applicable, signs and dates the form, and submits it to the Department of Revenue.

1. R - 6505 (01/06)
Individual Income Tax
Name and Address Change Form
Check all the boxes that this change affects: Effective Date of Change: ____________________
Your last individual income tax return was a joint return, and you are now establishing a residence
separate rate from the spouse with whom you filed that return.
Address change
Name change
Your name Social Security Number
last first mi
Spouse’s name Social Security Number
last first mi
Former Name last first mi
New Address Street Apt/Suite City/State Zip
New Zip
New City/State
New Suite
New Street
New Address
Old Address Street Apt/Suite City/State Zip
Old Suite Old Zip
Old City/State
Old Street
Old Addtress
Contact person and daytime telephone number
__________________________________________________________(______)_______-_______________
Your signature Date
Spouse’s signature Date
Request must be mailed or faxed to: Louisiana Department of Revenue
P. O. Box 201
Baton Rouge, LA 70821
Fax Number: 225-219-2348
6680