Employer'S Notice Of Change Form printable pdf download

(11/2007)

WYOMING EMPLOYER’S NOTICE OF CHANGE

Use this document to report changes of address, name, telephone number, addition or change of federal ID

number, change of account status, or sale of a portion or all of the business. Complete all sections that apply by

marking the appropriate choice and providing ALL information as requested in particular section, date and sign

below. Attach documentation as needed. (Unemployment Insurance =UI Workers Compensation = WC)

UI Number:

WC Number:

FEIN:

CHANGE IN NAME AND/OR FEDERAL IDENTIFICATION NUMBER:

Effective Date of change:

Legal Name Changed To:

Federal IRS/Employer Identification (FEIN)

Changed to:

Business Name Changed To:

Reason for change:

CHANGE IN ADDRESS:

Physical Address

(Attach list if more than one location)

Effective Date of Change:

Telephone Number:

UI Mailing Address for Tax Info:

WC Mailing Address for Tax Info

(WC only Summary

Reports)

UI Mailing Address for Benefit Info:

WC Mailing Address for General and Claims Info:

REQUEST TO CLOSE ACCOUNT:

BANKRUPTCY INFORMATION:

Bankruptcy Petition #:

Closed Business. Date Last Wages Paid:______________

Petition Date:

Operating Without Employees.

Chapter #:

Judicial District:

Date Last Wages Paid: ______________

Attorney Name:

If a Corporation or Limited Liability Company, does the

Address:

corporation or LLC continue to exist?

Yes

Telephone #:

CHANGE IN OWNERSHIP – INCLUDES SALE, MERGER, TRANSFER, LEASE:

Sold, Leased or Transferred

Date of Sale:

Seller’s Last Day of

PART of Business

Payroll:

ALL of Business

Does Seller Retain Some Business with Payroll?

Acquiring Party’s Name, Address, and Phone Number:

Portion Business Sold:

(identify location & assets)

Return to:

Unemployment Tax Division

Employer Services

PO Box 2760

Casper, WY 82602-2760

Phone: 307-235-3217

Fax: 307-235-3278

Printed Name _____________________________________ Signature _________________________________

Title_________________________________

Phone #___________________________ Date_____________

Employer'S Notice Of Change Form

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