Form 941bn-Me - Business Change Notification - 2016
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1Business Change
F
941BN-ME
ORM
Notifi cation
Complete this form to report a change in your withholding or unemployment insurance account, change
contact
information,
or to cancel your withholding or unemployment contributions account. Incomplete
forms will not be processed.
Mail to:
Maine Revenue Services, Central Registration Unit
Email: taxregistration@maine.gov
P.O. Box 1057, Augusta, ME 04332-0057
Fax: 207-287-6975
Step 1
Current Legal Name: __________________________ DBA: _________________________________________
Identify your
Current Address: ____________________________________________________________________________
business as
currently on
Current Phone Number:_______________________________________________________________________
fi le with Maine
Revenue
Withholding Account Number: __________________
UC Employer Account Number: ____________________
Services.
Step 2
New Legal Name: __________________________
New DBA: _____________________________________
List your
New ATTN Line: _____________________________________________________________________________
new contact
information;
New Address: ______________________________________________________________________________
enter only
if different
New Email Address: _________________________________________________________________________
(PRINT CLEARLY)
from current
/
/
information.
New Phone Number: ___________________________Effective Date of Change__________________________
NOTE: Do not enter a payroll processor’s address or other contact information
here.
Check the appropriate box or boxes to cancel your withholding or unemployment contributions account:
Step 3
Withholding Account
Unemployment Contributions Account
Request to
cancel account.
Reason for Cancellation:
(Do not report
cancellation
Business Closed (Do not include a seasonal or temporary business closure)
for a seasonal
shutdown
Business Sold to:
Name: __________________________
FEIN: _______________________
period.)
Address: ______________________________________
Phone: ______________________
_____________________________________________
Date Business Sold: _________________________________
Other ____________________________________________________________
Date the business no
/
/
/
/
longer had employees
Date of last payroll
______________________________________
________________________________
Step 4
Under penalties of perjury, I certify that the information contained on this form is true and correct.
Print Name:_________________________________________________________________________________
Sign and
mail your
Signature:_________________________________ Title:_________________________________________
report.
/
/
Date: ____________________________________ Daytime Phone: ____________________________________
For Paid Preparers Only
Paid Preparer’s Signature:____________________________________________________
/
/
Date:_____________________________
Phone: ___________________________
Firm’s Name (or yours if self-employed):_________________________________________
Address:____________________________________________________________________________________________________
EIN/SSN: _______________________________Maine Payroll Processor License Number: __________________________________
Rev.
10/16
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