Status Change Report Form

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STATE OF DELAWARE UNEMPLOYMENT INSURANCE
STATUS CHANGE REPORT
Use this form to report changes in status
EMPLOYER NAME
DELAWARE DEPARTMENT OF LABOR
EMPLOYER ACCOUNT #
DIVISION OF UNEMPLOYMENT INSURANCE
P.O. BOX 9953
WILMINGTON DE 19809
permanently
Covered employment was
discontinued on
Date
permanently
Operations were
discontinued on
Date
Business reorganized effective
Date
Business sold on
Date
Name change/correction
(
)
-
Telephone number
Mailing Address
(OUTSIDE REPRESENTATIVE MUST FILE A POWER OF ATTORNEY)
Change in ownership interest
Please explain
Federal ID #
X
Signature of owner or duly authorized representative
Title
Date

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