Form C-36 - Notice Of Change 2010 Page 2

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8. Will the new entity continue to operate this business?
Yes
No
If No, Explain:
__________________________________________________________________________________________________________________
_
__________________________________________________________________________________________________________________
_
9. Will you continue to pay wages after the change to your business occurs?
Yes
No
If "Yes", please provide reason: ______________________________________________________________________________________
__________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
10. Will you continue to operate a business under this legal entity?
Yes
No
If "Yes", please give the name and the nature of the business retained/continued: ______________________________________________
_________________________________________________________________________________________________________________
11. Will you be starting a new business under this legal entity?
Yes
No
If "Yes", provide the following:
Name of Business: ____________________________________________________________________
Nature of Business: _____________________________ Start Date: ________________ Date First Wages to be Paid: _______________
12. Will direction and control of the business remain the same?
Yes
No
C
Be advised that the sellar of a busines is required to disclose its experience rating to a potential buyer upon
request, in accordance with §1325(b)(1).
FOR LEASED BUSINESS ONLY
13. Did the title to any assets go to the lessee?
Yes
No
If, "Yes", please provide information on the assets:
__________________________________________________________________________________________________________________
_
__________________________________________________________________________________________________________________
_
__________________________________________________________________________________________________________________
_
14. Please describe in detail the nature of the leased business:
__________________________________________________________________________________________________________________
_
__________________________________________________________________________________________________________________
_
__________________________________________________________________________________________________________________
_
15. I understand that as the seller of a business, I am required to disclose the Unemployment Insurance tax expereince rating to
§
a potential buyer upon request, in accordajnce with
1325(b).
I have read and understand the proceededing statement.
16. Please describe any other changes not specified above: __________________________________________________________________
__________________________________________________________________________________________________________________
D
_
__________________________________________________________________________________________________________________
_
__________________________________________________________________________________________________________________
_
I CERTIFY THE ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Contact Name: __________________________________ Telephone: ________________ Ext. _______ Fax: _________________________
E
Signature: _______________________________________ Title: ___________________________________ Date: ____________________

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