Form Esd-Ark-236 - Report To Terminate Account
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1Arkansas Employment Security Department
ESD-ARK-236 (Rev. 04-97)
ATTN:
P.O. Box 2981 Little Rock, Arkansas 72203
Report to Terminate Account
STATUS
Telephone (501) 682-3268
ESD Account No. ____________________________
Date ___________________________________
1.
Employer ___________________________________________________________________________
2.
Name of Business To Be Terminated ______________________________________________________
3.
Address Where This Business Is Located __________________________________________________
4.
Employer’s Current Home Address ________________________________________________________
(Person’s Name If Partner or Corporate Officer)
__________________________,__________,__________________________,_____,_____________
(Street Address and/or Rural Route)
(P.O. Box)
(Town)
(State)
(Zip)
5.
Date of Change or Termination ____________________ Check below reason for Termination
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6.(a)
Bankruptcy filed under Chapter ______________________________
6.(a-1)
Foreclosure
If 6(a) or 6(a-1) is checked, the following information must be furnished:
_________________________________________________________________________________
(Name, Address, and Title of Either the Receiver, Trustee, or Employer’s Attorney)
_________________________________________________________________________________
(Name and Address where Payroll Records of Employer Shown in Item 1 are at present)
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6.(b)
Business Discontinued in Arkansas
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6.(c)
Regulation No. 8: You have not had employees for two complete, consecutive calendar quarters.
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6.(d)
Other Specify ____________________________________________________________________
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6.(e)
Merger/Consolidated with (Name of Firm) ______________________________________________
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6.(f)
Sold to (Successor’s Name) _________________________________________________________
If 6(e) or 6(f) is checked, the following information must be furnished:
_______________________________________________________________________________________
(Successor’s Business Name and Mailing Address)
7.(a) Did you (The Employer Named in Item 1) continue to operate any other business with employees (In
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Arkansas) on the date shown in item 5 above?
Yes
No
7.(b) If “Yes,” list business(es) still being operated:
Name of Business
Street Address
Town/State/Zip
No. of Employees
________________________________________________________________________________________
________________________________________________________________________________________
7.(c) If 7(a) is checked “No,” do you agree that your account, including your experience rate should be
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transferred to the successor shown in Item 6(f)?
Yes
No
For Field Auditor’s Use Only
201 (was) (was not) submitted on
Successor on________________
(Signed)
(Title)
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