Form Ldol Es4 A - Employer'S Report Of Change Form
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1LOUISIANA DEPARTMENT OF LABOR
EMPLOYER'S
OFFICE OF REGULATORY SERVICES
REPORT OF CHANGE
P. O. BOX 94186
BATON ROUGE, LA 70804-9186
Complete form online, print, then fax to 225-342-1943.
YES
NO
1.
STATE ID NUMBER:
2.
HAS BUSINESS CEASED OPERATION?
2A. IF YES, COMPLETE SECTIONS B, C, AND/OR D
AS APPLICABLE.
PART A.
PART B.
CURRENT ACCOUNT INFORMATION
CHANGES TO ACCOUNT INFORMATION
EMPLOYER NAME, DBA NAME & MAILING ADDRESS:
IF YOU HAVE A NAME CHANGE, ALSO ANSWER PART C
3A.
3B.
4A. PHYSICAL LOCATION OF BUSINESS IN LOUISIANA:
4B. PHYSICAL LOCATION OF BUSINESS IN LOUISIANA:
5A. BUSINESS PHONE NUMBER:
5B.
6A. BUSINESS FAX NUMBER:
6B.
7A.
7B.
E-MAIL ADDRESS:
8A. LOUISIANA REVENUE NUMBER:
8B.
9A. FEDERAL ID NUMBER (FEIN)
9B.
:
(ALSO ANSWER PART C)
IF FEIN CHANGE IS FOR NEW OWNER OR DUE TO CONTRACT WITH PEO/LEASING ORGANIZATION, ANSWER PART C.
C.
YES NO
CHANGES IN OWNERSHIP OR OPERATIONS:
1. HAS THE LEGAL STATUS OF YOUR BUSINESS CHANGED?
(EXAMPLE: A BUSINESS CHANGES ITS LEGAL STATUS WHEN IT CHANGES FROM A SOLE PROPRIETOR TO A CORPORATION OR VICE VERSA)
2. HAS THE BUSINESS NAMED IN # 3A PURCHASED ANOTHER BUSINESS?
3. HAS THE BUSINESS NAMED IN # 3A BEEN SOLD?
4. DO YOU HAVE A CONTRACT WITH A PEO/LEASING ORGANIZATION?
IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS IN PART C, PROCEED TO PART D
D.
PROVIDE THE FOLLOWING INFORMATION:
1. EFFECTIVE DATE OF CHANGE:
2. DATE LAST WAGES PAID FOR ACCOUNT IN # 3A:
ENTER INFORMATION ABOUT BUSINESS PURCHASED, NEW OWNER OR PEO:
3. NAME:
4. TRADE NAME / DBA NAME:
5. STREET ADDRESS:
6. CITY, STATE & ZIP CODE:
7. CONTACT PERSON:
PHONE NUMBER:
E.
NAME CHANGES FOR CORPORATE ENTITIES CANNOT BE UPDATED UNTIL YOU PROVIDE CERTIFICATION OF
THE CHANGE FROM THE OFFICE OF THE SECRETARY OF STATE.
ENTER THE NAME & PHONE NUMBER OF THE PERSON TO CONTACT REGARDING INFORMATION FOR THIS ACCOUNT.
SIGNATURE:
PRINTED NAME:
TITLE:
PHONE:
NOTICE: YOU CAN NOW DIRECTLY POST YOUR JOB OPENINGS ON OUR
WEB SITE
LDOL ES4 A REV. 03/2006
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