Form Uia 1772 - Discontinuance Or Transfer Of Payroll Or Assets In Whole Or Part - 2012
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4State of Michigan
Authorized By
UIA 1772
Department
of
Licensing
and
Regulatory Affairs
MCL 421.1 et
seq.
Rev. 8/12
Unemployment
Insurance Agency
Steve Arwood
3024 W
Grand
Blvd,
Suite
11-500, Detroit,
Ml
48202
Rick
Snyder
DIRECTOR
GOVERNOR
•
(855) 484-2636
•
(313) 456-2300
Reset Form
Discontinuance or Transfer of Payroll or Assets in Whole or Part
Information shown on this report is used to determine termination of liability under Section 24 of the Michigan
Employment Security (MES) Act. Completion of this report is required even though you may not be currently
employing any workers. Failure to provide this information may result in a determination being made based on
information available to the Agency. Penalties may be imposed under Section 54(a) or 54(b) of the MES Act for an
intententional failure to comply with State law.
Employee Leasing companies must complete a separate Form UIA 1772 for each client entity terminating
its contract.
PART 1: EMPLOYER INFORMATION
1. Name and Address used prior to discontinuance or transfer of payroll or assets in whole or part.
a) Name:
UIA Employer Account Number (EAN):
b) Business Address:
c) Telephone:
Federal Employer ID (FEIN):
2. Current name and address used since discontinuance or transfer of payroll or assets in whole or part.
a. Name:
b. Business Address:
c. Telephone:
3. Provide the following information concerning the owner(s), partners, corporate officers, LLC member(s), etc.,
of the organization and the person(s) who safeguard the company’s books and records. If necessary, please
attach additional pages to provide information on all owners.
a. Name:
SSN:
Birth Date:
Address:
Title:
Telephone:
Record Holder:
Yes No
b. Name:
SSN:
Birth Date:
Address:
Title:
Telephone:
Record Holder:
Yes No
c. Name:
SSN:
Birth Date:
Address:
Title:
Telephone:
Record Holder:
Yes No
d. Name:
SSN:
Birth Date:
Address:
Title:
Telephone:
Record Holder:
Yes No
e. Name:
SSN:
Birth Date:
Address:
Title:
Telephone:
Record Holder:
Yes No
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