IT WHC 
                          Change of Ohio Employer, Name, Address or Status                                                             Rev. 1/08 
Please use the top and bottom of this form to report any changes of mailing address, name, merger information or out-of-business informa-
tion. If this change is because you are out of business, you must fi le a fi nal reconciliation for the final period you were in business on form 
IT 941. If a change in ownership or a change in business status (such as changing from a sole proprietorship to a corporation) occurs, 
and you receive a new federal employer identifi  cation number (FEIN), you must fi le a final     reconciliation form IT 941 for the old account 
and complete the bottom of this form to obtain a new Ohio withholding account number. If a merger has taken place, the nonsurvivor must 
fi le a fi nal reconciliation form IT 941 and complete the merger information on the bottom of this form. 
                                    Ohio Tax ID No.                                               FEIN 

         Previous Business Name and Mailing Address                                   New Name, Mailing and Location Address 
 Business name                                                             Business name 

 Address                                                                   Owner’s name/responsible party 

 City State ZIP code                             New mailing address 

                                                                           City State ZIP code                               
Please send your completed form to us by fax or by mail. 
                                                                           Physical location (street address and number)    
Fax to: 614-387-1851 or 
Mail to:  Ohio Department of Taxation                                      City State ZIP code                               
          Taxpayer Services Division
 Registration Section                                                      NAICS code                          Telephone number 
          P.O. Box 182215 
          Columbus, OH 43218-2215 

 Indicate changes or additions only by checking the appropriate box and entering the information requested. 

      Out of business           Effective date  M M D D Y Y                            No employees at this time – 
                                                                                       inactivate account 

      Merged                    Effective date  M M D D Y Y                           Survivor’s name 

      Survivor’s                                             Survivor’s  
      federal ID                                             Ohio ID 

      Business status           Effective date  M M D D Y Y                            New business type 
       change 
                                                                                       
       New federal ID                                                                 New name 
      to be registered 

      Form IT 941, the fi nal reconciliation, is enclosed.