Form Uia 1925 - Request For Name And/or Address Change - 2014
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1•
UIA 1925
Authorized by
State of Michigan
(Rev. 08-14)
MCL 421.1, et seq.
Department of Licensing and Regulatory Affairs
UNEMPLOYMENT INSURANCE AGENCY
REQUEST FOR NAME AND/OR ADDRESS CHANGE
Reset Form
Social Security Number:
________________________
Complete using black or blue ink – Do not use pencil.
CHECK APPROPRIATE BOX:
Name Change
Address Change
NAME CHANGE
*FOR A NAME CHANGE, SUBMIT A COPY OF LEGAL PROOF THAT DOCUMENTS THE CHANGE
*After you filed your claim for unemployment benefits, you reported your name had changed since you last
claimed benefits. Your claim has been processed under your former name. To change your name, you
must provide the Unemployment Insurance Agency (UIA) with a signed statement and supporting legal
documentation.
Print your new name: ___________________________________
______________________________
____
Last
First
M.I.
Print your former name: _________________________________
______________________________
____
Last
First
M.I.
Reason for Change:
Marriage
Divorce
Personal Choice
Attach a copy of the legal basis (e.g., marriage license, probate court document, etc.) for making the change.
ADDRESS CHANGE
Old Address: ___________________________________________________________________________________
Street Address
City
State
Zip Code
New Address: _________________________________________________________________________________
Street Address
City
State
Zip Code
Telephone Number:
___________________________
If you have relocated outside of Michigan, will it be for more than 4 weeks? .............
Yes
No
(If you answered “Yes,” your claim will be changed to an Interstate Benefit claim.)
I know the law provides penalties of fine and/or imprisonment and/or community service for any false statement(s). I certify
that the information reported on this form is true and correct to the best of my knowledge.
Your Signature: _____________________________________________________ Date: ____________________
If you have any questions about this form, contact our Inquiry Line at 1-866-500-0017 (TTY customers use 1-866-366-
0004), use your Michigan Web Account Manager (MiWAM) to get a response for your question, or visit one of your Problem
Resolution Offices (PRO).
RETURN COMPLETED FORM TO:
Unemployment Insurance Agency
PO Box 169
Grand Rapids, MI 49501-0169
FAX: 1-517-636-0427
•
*019251408*
LARA is an equal opportunity employer/program.
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