4137 Social Security and Medicare Tax on Unreported Tip Incom

3
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Date

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
INSTRUCTIONS TO PRINTERS
FORM 8822, PAGE 1 of 2
PRINTS: HEAD to HEAD
MARGINS: TOP 13mm (1⁄2 ”), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
1
FLAT SIZE: 216mm (8 ⁄2 ”) x 279mm (11”)
PERFORATE: (NONE)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form

8822

Part I

Date

Signature

O.K. to print
Revised proofs
requested

Change of Address
䊳

(Rev. December 2005)
Department of the Treasury
Internal Revenue Service

Action

䊳

OMB No. 1545-1163

Please type or print.
䊳

See instructions on back.

Do not attach this form to your return.

Complete This Part To Change Your Home Mailing Address

Check all boxes this change affects:
1
Individual income tax returns (Forms 1040, 1040A, 1040EZ, 1040NR, etc.)
䊳 If your last return was a joint return and you are now establishing a residence separate
䊳
from the spouse with whom you filed that return, check here
2

Gift, estate, or generation-skipping transfer tax returns (Forms 706, 709, etc.)
䊳 For Forms 706 and 706-NA, enter the decedent’s name and social security number below.
䊳

䊳

Decedent’s name

Social security number
3b

3a

Your name (first name, initial, and last name)

4a

Spouse’s name (first name, initial, and last name)

5

Prior name(s). See instructions.

6a

Old address (no., street, city or town, state, and ZIP code). If a P.O. box or foreign address, see instructions.

Apt. no.

6b

Spouse’s old address, if different from line 6a (no., street, city or town, state, and ZIP code). If a P.O. box or foreign address, see instructions.

Apt. no.

7

New address (no., street, city or town, state, and ZIP code). If a P.O. box or foreign address, see instructions.

Apt. no.

Part II

4b

Your social security number

Spouse’s social security number

Complete This Part To Change Your Business Mailing Address or Business Location

Check all boxes this change affects:
8
Employment, excise, income, and other business returns (Forms 720, 940, 940-EZ, 941, 990, 1041, 1065, 1120, etc.)
9
Employee plan returns (Forms 5500, 5500-EZ, etc.)
10
Business location
11a Business name
11b Employer identification number

Old mailing address (no., street, city or town, state, and ZIP code). If a P.O. box or foreign address, see instructions.

Room or suite no.

13

New mailing address (no., street, city or town, state, and ZIP code). If a P.O. box or foreign address, see instructions.

Room or suite no.

14

New business location (no., street, city or town, state, and ZIP code). If a foreign address, see instructions.

Room or suite no.

12

Part III

Signature
Daytime telephone number of person to contact (optional)

Sign
Here

䊳
䊳

䊳

(

)

Your signature

Date

If joint return, spouse’s signature

Date

For Privacy Act and Paperwork Reduction Act Notice, see back of form.

䊳
䊳

If Part II completed, signature of owner, officer, or representative Date

Title
Cat. No. 12081V

Form

8822

(Rev. 12-2005)

3
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8822, PAGE 2 of 2
PRINTS: HEAD to HEAD
MARGINS: TOP 13mm (1⁄2 ”), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
1
FLAT SIZE: 216mm (8 ⁄2 ”) x 279mm (11”)
PERFORATE: (NONE)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 8822 (Rev. 12-2005)

Page

Purpose of Form
You can use Form 8822 to notify the
Internal Revenue Service if you changed
your home or business mailing address or
your business location. If this change also
affects the mailing address for your
children who filed income tax returns,
complete and file a separate Form 8822 for
each child. If you are a representative
signing for the taxpayer, attach to Form
8822 a copy of your power of attorney.
Changing both home and business
addresses? If you are, use a separate
Form 8822 to show each change.

Prior Name(s)
If you or your spouse changed your name
because of marriage, divorce, etc.,
complete line 5. Also, be sure to notify the
Social Security Administration of your new
name so that it has the same name in its
records that you have on your tax return.
This prevents delays in processing your
return and issuing refunds. It also
safeguards your future social security
benefits.

Addresses
Be sure to include any apartment, room, or
suite number in the space provided.

P.O. Box
Enter your box number instead of your
street address only if your post office does
not deliver mail to your street address.

Alabama, Delaware, Florida,
Georgia, North Carolina,
Rhode Island, South
Carolina, Virginia
Arkansas, Kansas,
Kentucky, Louisiana,
Mississippi, Oklahoma,
Tennessee, Texas, West
Virginia

Signature
If you are completing Part II, the owner, an
officer, or a representative must sign. An
officer is the president, vice president,
treasurer, chief accounting officer, etc. A
representative is a person who has a valid
power of attorney to handle tax matters or
is otherwise authorized to sign tax returns
for the business.

Where To File
Send this form to the Internal Revenue
Service Center shown next that applies to
you.
If you checked the box on line
2, see Filers Who Checked the
Box on Line 2 or Completed
Part II for where to file this
CAUTION form.

Filers Who Checked the Box on
Line 1 and Completed Part I
IF your old home mailing
address was in . . .
District of Columbia, Maine,
Maryland, Massachusetts,
New Hampshire, New York,
Vermont

THEN use this
address . . .

Fresno, CA 93888

Connecticut, Illinois,
Indiana, Iowa, Michigan,
Minnesota, Missouri, North
Dakota, Ohio, Wisconsin

Kansas City, MO 64999

New Jersey, Pennsylvania

Philadelphia, PA 19255

American Samoa
Guam:
Nonpermanent residents
Puerto Rico (or if excluding
income under Internal
Revenue Code
section 933)
Virgin Islands:
Nonpermanent residents
Dual-status aliens
Those filing Form 4563

Philadelphia, PA 19255

Foreign country:
U.S. citizens and those
filing Form 2555 or
Form 2555-EZ
All APO and FPO addresses

Austin, TX 73301

Guam:
Permanent residents

Department of Revenue
and Taxation
Government of Guam
P.O. Box 23607
GMF, GU 96921

Virgin Islands:
Permanent residents

V.I. Bureau of
Internal Revenue
9601 Estate Thomas
Charlotte Amalie
St. Thomas, VI 00802

Filers Who Checked the Box on
Line 2 or Completed Part II
IF your old business address
was in . . .

THEN use this
address . . .

Connecticut, Delaware,
District of Columbia, Illinois,
Indiana, Kentucky, Maine,
Maryland, Massachusetts,
Michigan, New Hampshire,
Cincinnati, OH 45999
New Jersey, New York, North
Carolina, Ohio, Pennsylvania,
Rhode Island, South Carolina,
Vermont, Virginia, West
Virginia, Wisconsin
Alabama, Alaska, Arizona,
Arkansas, California,
Colorado, Florida, Georgia,
Hawaii, Idaho, Iowa,
Kansas, Louisiana,
Minnesota, Mississippi,
Missouri, Montana,
Nebraska, Nevada, New
Mexico, North Dakota,
Oklahoma, Oregon, South
Dakota, Tennessee, Texas,
Utah, Washington,
Wyoming
Outside the United States

Andover, MA 05501

Austin, TX 73301

Alaska, Arizona, California,
Colorado, Hawaii, Idaho,
Montana, Nebraska,
Nevada, New Mexico,
Oregon, South Dakota,
Utah, Washington,
Wyoming

Foreign Address
Enter the information in the following order:
city, province or state, and country. Follow
the country’s practice for entering the
postal code. Please do not abbreviate the
country name.

Atlanta, GA 39901

Ogden, UT 84201

Philadelphia, PA 19255

2

Privacy Act and Paperwork Reduction
Act Notice. We ask for the information on
this form to carry out the Internal Revenue
laws of the United States. We may give the
information to the Department of Justice
and to other Federal agencies, as provided
by law. We may give it to cities, states, the
District of Columbia, and U.S.
commonwealths or possessions to carry
out their tax laws. We may also disclose
this information to other countries under a
tax treaty, to federal and state agencies to
enforce federal nontax criminal laws, or to
federal law enforcement and intelligence
agencies to combat terrorism.
Our legal right to ask for information is
Internal Revenue Code sections 6001 and
6011, which require you to file a statement
with us for any tax for which you are liable.
Section 6109 requires that you provide
your social security number on what you
file. This is so we know who you are, and
can process your form and other papers.
You are not required to provide the
information requested on a form that is
subject to the Paperwork Reduction Act
unless the form displays a valid OMB
control number. Books or records relating
to a form or its instructions must be
retained as long as their contents may
become material in the administration of
any Internal Revenue law. Generally, tax
returns and return information are
confidential, as required by section 6103.
The use of this form is voluntary.
However, if you fail to provide the Internal
Revenue Service with your current mailing
address, you may not receive a notice of
deficiency or a notice and demand for tax.
Despite the failure to receive such notices,
penalties and interest will continue to
accrue on the tax deficiencies.
The time needed to complete and file
this form will vary depending on individual
circumstances. The estimated burden for
individual taxpayers filing this form is
approved under OMB control number
1545-0074 and is included in the estimates
shown in the instructions for their individual
income tax return. The estimated burden
for all other taxpayers who file this form is
16 minutes.
If you have comments concerning the
accuracy of this time estimate or
suggestions for making this form simpler,
we would be happy to hear from you. You
can write to the Internal Revenue Service,
Tax Products Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111 Constitution
Ave. NW, IR-6406, Washington, DC 20224.
Do not send the form to this address.
Instead, see Where To File on this page.