Report Of Changes Form
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1REPORT OF CHANGES
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
UCHNG (10/02)
PO BOX 52027
PHOENIX, AZ 85072-2027
ARIZONA ACCOUNT NUMBER
Telephone (602) 248-9396
Report ANY CHANGES PROMPTLY (ownership. legal form, operation, payroll
method, or address of your business) as required by Arizona Administrative
FEDERAL ID NO.
Code R6-3-1703. Failure to do so could result in additional cost to you later.
A. Change in Mailing Address
NEW ADDRESS (PO Box No. or No., Street)
MAIL NOTICES OF UNEMPLOYMENT CLAIMS TO (PO Box No. or No., Street
City, State, ZIP
City, State, ZIP
PHONE NO.
PHONE NO.
(
)
(
)
B. Change in Business’ E-mail Address
E-MAIL ADDRESS
C. Change in Arizona Ownership / Operation
All of the Arizona business was transferred to (complete Item 1 below), as of _______________________________ (date)
Part of the Arizona business was transferred to (complete Item 1 below), as of ______________________________ (date)
In the portion of business transferred, did you during the current or preceding calendar year: 1) employ
one or more individuals for a part of a day in at least 20 weeks, or pay $1,500 or more in wages in a
calendar quarter, OR 2) if the business is agricultural, did you employ 10 or more individuals for a part of
a day in at least 20 weeks, or pay $20,000 or more wages in a calendar quarter?
Yes
No
No ownership change occurred, but payroll is paid by (complete Item 1 below), as of _________________________ (date)
No ownership change occurred, but leasing employees (complete Item 1 below), as of ________________________ (date)
Business was discontinued without being sold, leased or transferred, as of _________________________________ (date)
Business is operating in Arizona, but ceased paying wages, as of ________________________________________ (date)
NAME OF NEW OWNER, PARTNERSHIP, CORPORATION, PAYROLLER, LEASING COMPANY
PHONE NO.
ITEM 1
(
)
ADDRESS (PO Box No. or No., Street, City, State, ZIP)
ARIZONA EMPLOYER ACCOUNT NO.
NAME OF BUSINESS YOU RETAINED
PHONE NO.
ITEM 2
(
)
ADDRESS (PO Box No. or No., Street, City, State, ZIP)
D.
SIGNATURE AND TITLE OF OWNER, PARTNER, CORPORATE OFFICER OR AGENT
DATE
MAILING OR FORWARDING ADDRESS (PO Box No. or No., Street, City, State, ZIP)
PHONE NO.
(
)
FOR AGENCY USE ONLY
C
I
C
HANGE OF OWNER
NACTIVE
OMMENTS
M
_______________________
S
ERGE INTO
USPEND
T
_______________________
E
E
RANSFER TO
STABLISHED IN
RROR
R
__________________
T
EVISE CLOSE CODE
ERMINATE
C
________________________
LOSE DATE
I
DATE
NITIAL
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