Form Dws-Ark-236 - Report To Terminate Account
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1Department of
WORKFORCESERVICES
DWS-ARK-236 (Rev. 01-07)
Report to Terminate Account
Employer Accounts Services • P.O. Box 8007
Little Rock, AR 72203-8007 • Telephone (501) 682-3798
DWS Account No. ___________________________
Date __________________________
1.
Employer ______________________________________________________________
2.
Name of Business To Be Terminated _________________________________________
3.
Address Where This Business Is Located _____________________________________
4.
Date of Change or Termination _______________ Check below reason for Termination
5.(a)
Bankruptcy filed under Chapter ______________________________
5.(b)
Foreclosure
o
o
If 5(a) or 5(b) is checked, the following information must be furnished:
_________________________________________________________________________________
(Name, Address, and Title of Either the Receiver, Trustee, or Employer’s Attourney)
_________________________________________________________________________________
(Name and Address where Payroll Records of Employer Shown in Item 1 are at present)
5.(c)
Business Discontinued in Arkansas
o
5.(d)
Regulation No. 8: You have not had employees for two complete, consecutive calendar quarters.
o
5.(e)
Other Specify ___________________________________________________________________
o
5.(f)
Merger/Consolidated with (Name of Firm) _____________________________________________
o
5.(g)
Sold to (Successor’s Name) _______________________________________________________
o
If 5(f) or 5(g) is checked, the following information must be furnished:
______________________________________________________________________________________
(Successor’s Business Name and Mailing Address)
6.(a) Did you (The Employer Named in Item 1) continue to operate any other business with employees (In
Arkansas) on the date shown in item 4 above?
Yes
No
o
o
6.(b) If “Yes,” list business(es) still being operated:
Name of Business
Street Address
Town/State/Zip
No. of Employees
______________________________________________________________________________________
______________________________________________________________________________________
6.(c) If 6(a) is checked “No,” do you agree that your account, including your experience rate, should be
transferred to the successor shown in Item 5(g)?
Yes
No
o
o
For Field Auditor’s Use Only
201 (was) (was not) submitted on
Successor on________________
(Signed)
(Title)
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