NOTICE OF CHANGE OR DISCONTINUANCE OF BUSINESS 
FEIN:                                                    CHANGE EFFECTIVE AS OF: 

CURRENT BUSINESS NAME:                                   NAME CHANGED TO: 

D.B.A.:                                                  D.B.A. CHANGED TO: 

CURRENT BUSINESS ADDRESS:                                BUSINESS ADDRESS CHANGED TO: 

MAILING ADDRESS :                                        MAILING ADDRESS CHANGED TO: 

Instructions Place an 'X' in all boxes that apply.  Complete all information for the change.  Write any 
             comments or explanations on the back of this form. 

     1 .  IRS has assigned use a federal identification number: 

     2 .  Our federal employer identification number is wrong. 
        The correct number is: 

     3 .  a. We have incorporated. Our Corporate name is: 
        b. Our corporate federal employer identification number is:

     4 .  Discontinue our withholding tax registration.  We no longer have business activity in Springfield. 
        We closed our business on:   
        We sold our entire business on:              or we sold part of our business on: 
        To:   
        Their FEIN is:   

     5 .  Address and phone number where we may contact you following discontinuance of your business: 

     6 .  Give name, address and phone number of person who will have custody of your books and records 
        of the discontinued business: 

     7 .  Change in ownership (Please explain on the back of this form). 

     8 .  Effective            , we have changed our fiscal year ending form:            to: 

     9 .  Other changes (Please explain on back of this form). 

x 
  SIGNATURE OF PREPARER               PRINT NAME & TITLE           DATE             PHONE NUMBER 

       MAIL THIS FORM TO: SPRINGFIELD INCOME TAX DEPARTMENT, 601 AVENUE A, SPRINGFIELD, MI 49037-7774 

EXCEL-NOTICE OF CHANGE OR DISCONTINUANCE OF BUSINESS