Form Ui-50a - Notice Of Change - 1998 (Page 2 of 2) in pdf

CONTENTS

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4. LEGAL OR INSOLVENCY PROCEEDINGS

____ Foreclosure; ____ Receivership; ___ Bankruptcy; ____ Assignment for benefit of creditors

Type ____ Date _____ Case Number ______________________________________________________________

5. DEATH OF

_____ Owner ____ Partner

Name of deceased ____________________________________________________

Estate in probate ______ Yes

______ No

6. If any of the items 3 through 5 are checked, furnish the following information:

a. The trade name, address and type of business operated by EMPLOYING UNIT(S) WHICH ACQUIRED ALL OR

PART OF YOUR ENTERPRISE:

Trade Name

Business Address

Type of Business

_____________________________________________________________________________________________

b. The owner, partners, corporate officers, or trustee in the EMPLOYING UNIT(S) WHICH ACQUIRED ALL OR

PART OF YOUR ENTERPRISE:

Name

Residence Address

Telephone Number

Title

_____________________________________________________________________________________________

7. Furnish the following information with respect to your ILLINOIS operations if you disposed of or leased (1) ONLY

A PORTION OF YOUR BUSINESS ENTERPRISE, or (2) YOUR ENTIRE BUSINESS ENTERPRISE TO TWO

OR MORE EMPLOYING UNITS:

a. The trade names, address and types of business of the portion of the enterprise you retained or continued to

operate:

Trade Name

Business Address

Type of Business

_____________________________________________________________________________________________

b. At the close of the calendar month which ended nearest to the 30th day prior to the date of disposition or lease:

(1) Dollar amount and percent of business assets in the portion disposed of/leased to each employing unit

listed under item 6a.

$ _______ _____ % in portion acquired by ______________________________________________________

c. During the pay period which ended nearest to the 30th day prior to the date of disposition or lease:

(1) Total number of individuals employed by your entire enterprise ___________________ .

(2) Total number of individuals employed by the portion subsequently disposed of or leased to each

employing unit listed under item 6a.

Number of employees __________ in portion acquired by __________________________________________

d. For the calendar month which ended nearest to the 30th day prior to the date of disposition or lease:

(1) Gross income of your entire enterprise $_________________.

(2) Gross income of the portion subsequently disposed of or leased to each employing unit listed under

item 6a.

Gross income $ __________ of portion acquired by _______________________________________________

CERTIFICATION: I HEREBY CERTIFY THAT THE FOREGOING INFORMATION AND THAT CONTAINED IN ANY

ATTACHED SHEETS SIGNED BY ME IS TRUE AND CORRECT, AND THAT I AM AUTHORIZED TO EXECUTE THIS

REPORT ON BEHALF OF THE EMPLOYING UNIT NAMED.

BUSINESS NAME _____________________________________ DATE SIGNED AND SUBMITTED _________________

SIGNED BY __________________________________________ OFFICIAL TITLE _______________________________

HOME ADDRESS OF OFFICIAL _________________________ HOME TELEPHONE NUMBER ___________________

THIS REPORT MUST BE SIGNED BY OWNER, PARTNER, OR OFFICER. IF SIGNED BY ANY OTHER PERSON,

A POWER OF ATTORNEY GIVING SUCH INDIVIDUAL AUTHORITY TO SIGN MUST BE ATTACHED.

This state agency is requesting information that is necessary to accomplish the statutory purpose as outlined under 820 ILCS 405/100-3200. Disclosure of this information is

REQUIRED. Failure to disclose this information may result in statutorily prescribed liability and sanction, including penalties and/or interest. This form has been approved by

the Forms Management Center.

Form Ui-50a - Notice Of Change - 1998 Page 2

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