ROC-1 State Form 52039 (R2/ 10-07) Correct / Change of Responsible Officer Information This form is available in a PDF ‘fillable’ 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 officers for your business. Note: You cannot use this form if the Internal Revenue Service has required you to obtain a new Federal Identification Number. A change in Federal Identification Number requires a new registration with the Indiana Department Of Revenue. Business Information Federal Identification Number (FEIN) Indiana Taxpayer Identification Number (TID) Legal Name of the Entity Doing Business As Name (DBA) Street Address City State Zip Code Old Responsible Officer Information Social Security No. Last Name, First Name, Middle Initial, Suffix Social Security No. Last Name, First Name, Middle Initial, Suffix Title Address City State Zip Code Effective Date State Zip Code Begin Date start: / end: New Responsible Officer Information Title Address City I affirm that the changes provided are correct: Signature of the Person Submitting Changes: Printed Name of the Person Submitting Changes: Phone: 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 Indiana 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 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS Correct/Change of Responsible Officer Information NOTICE: All information, including the supporting documentation, must be provided before the form will be considered to be a valid request. If more space is needed to record your changes, you may attach a separate sheet. Business Information Section Please provide the following required information: 1. 2. 3. 4. Federal (FEIN) and Indiana (TID) Identification Numbers Legal names of the entity submitting the change request DBA (Doing Business As) Name of the entity (if different from the legal name) Business mailing address Old Responsible Officer 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 provided. Documentation may include: Corporate Minutes, Registration Letter, Financial Documents showing removal as a signatory of bank account, Affidavit from another officer; etc... New Responsible Officer Information Complete all applicable columns. This information is necessary to ensure we correctly identify and add the new officer. Note: Supporting documentation must be provided. Documentation may include: Corporate Minutes, Financial Documentation showing the addition of individual as Signatory of Bank Account, Affidavit from another officer; etc... This change/correction must be submitted and signed by an existing owner, partner or corporate officer 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 officer. American LegalNet, Inc. www.FormsWorkflow.com