Form Uia 1025 - Employer Request For Address/name Change - 2011
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LICENSING AND REGULATORY AFFAIRS
UNEMPLOYMENT INSURANCE AGENCY
UIA 1025
Authorized by
Tax Office
(Rev. 5-11)
MCL 421.1, et seq.
P.O Box 8068 • Royal Oak, Michigan 48068-8068
Employer Request For Address/Name Change
Current Employer Name: ______________________________________________________________________________________________
UIA Employer Account No.: ________________________________ Federal Employer ID No. (FEIN): _________________________________
New Employer Name: ________________________________________________________________________________________________
DBA: ______________________________________________________________________________________________________________
E-Mail Address: ______________________________________________________________________________________________________
PLEASE DO NOT SUBMIT THIS FORM UNLESS THERE HAS BEEN A CHANGE IN NAME OR ADDRESS
Physical Location of the Business
Mailing Address
No Post Office boxes, please.
(Include both addresses, even if only one has changed.)
Street:
Street:
City:
City:
State:
Zip Code:
-
State:
Zip Code:
-
E-Mail Address:
E-Mail Address:
Mailing Address is:
Accountant/Employer Rep*
Corporate Office
Owner
Employer's Telephone Number:
*
To request a change of mailing address to an employer representative (CPA, Service Bureau, Attorney, etc.) YOU MUST FILE A POWER
OF ATTORNEY AUTHORIZATION FORM.
CHANGING ACCOUNT INFORMATION: If you have discontinued or ceased business activity, discontinued employment, sold or trans-
ferred ownership of all or part of your business, formed a new partnership or corporation, merged, or changed your status as a sole
proprietorship or corporation, you must file a Report of Discontinuance or Disposition of Business, Form UIA 1772.
To request Form UIA 1772, check here
or call the number(s) listed below.
THE CORRECTION OF A PREVIOUSLY FILED REPORT (UIA 1020) MUST BE MADE ON AN Amended Quarterly Tax Report, Form UIA 1021.
Other changes, including FEIN changes or bankruptcy filing, etc., must be submitted in writing with supporting documentation. YOU
MUST sign and date this form, giving your title and telephone number, before changes will be accepted.
Preparer: ____________________________________________
Title: ________________________________________________
Date: _______________________
Preparer Telephone No.: _____________________________
If you need assistance, telephone 1-800-638-3994, outside Michigan 1-313-456-2180.
Mail this form with your changes to the above address, or fax to (313) 456-2130.
FORMS MAY BE FAXED TO YOU 24 HOURS A DAY BY CALLING: 1-800-638-3994 FORMS CAN ALSO BE OBTAINED ON OUR WEBSITE:
.
LARA is an Equal Opportunity Employer/Program.
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