Form Ia 15 - Change Of Business Information For The Unemployment Insurance Program Page 2
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2Part C – Address/Telephone Information
Fill in any changes to your mailing addresses or physical location. If you want to have your UI mail sent to an address other than
your place of business, complete number 4 below.
1. Mailing Address: This is your business mailing address where your Withholding Tax (WT) and Unemployment
Insurance (UI) mail will be delivered. If you elect to have your UI mail sent to an address other than your
place of business, complete under number 4 below.
Street or PO Box: _______________________________________________________________________________
City:_______________________________________________________ State: _________ZIP Code:____________
(
)
-
Telephone:
ext:________________
2. Physical Address: This is the physical location of your business, if different from the Mailing Address in number 1.
Street: ________________________________________________________________________________________
City:_______________________________________________________ State: _________ZIP Code:____________
3. Location of Books/Records: This is the physical location where your Books and Records are maintained.
Street: ________________________________________________________________________________________
City:_______________________________________________________ State: _________ZIP Code:____________
(
)
-
Telephone:
ext:________________
Optional Addresses
4. Agent Address (C/O): Complete this if all your UI mail should be sent to an address other than your business
address.
C/O: __________________________________________________________________________________________
Street or PO Box: _______________________________________________________________________________
City:_______________________________________________________ State: _________ZIP Code:____________
(
)
-
Telephone:
ext:________________
5. LO 400 Form - Notice of Entitlement and Potential Charges Address: If completed, this is where the LO 400 will
be sent. (It is mailed each time a former employee files a claim for Unemployment Insurance benefits.)
C/O: __________________________________________________________________________________________
Street or PO Box: _______________________________________________________________________________
City:_______________________________________________________ State: _________ZIP Code:____________
(
)
-
Telephone:
ext:________________
I certify that the information on this form is true, correct, and complete to the best of my knowledge.
Signature
Title
(
)
Telephone number
Date
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