Form 5a - Employer'S Report Of Change - 2008
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1Louisiana Workforce Commission
Employer’s Report of Change
U.I. Tax Liability and Adjudication Unit
PO Box 94050
DISCARD THIS PAGE IF THERE ARE NO CHANGES
Baton Rouge, LA 70804-9050
PART A. Current Account Information
1. Employer Account Number
PART B. Correct Information
3A. Employer Name, DBA, and Mailing Address
2. Is this a Final Report?
YES
NO
3B. Enter corrections to Items 3A – 9A
Answer Part C if any changes to Name or FEIN
DBA:
Address:
City:
State:
Zip:
4A. Physical Location of Business in Louisiana
4B.
5A. Business Phone Number
Ext.
5B.
6A. Business Fax Number
6B
7A. E-Mail Address
7B.
8A. Louisiana Revenue Number
8B.
9A. Federal ID Number (FEIN)
9B.
If FEIN change is for new owner or due to contract with PEO/Leasing, answer PART C.
text
PART C. Current Information
2. Has the business named in 3A purchased another business?
Y
N
1. Has the legal status of your business changed?
Y
N
3. Has the business named in 3A been sold?
Y
N
(EXAMPLES OF LEGAL STATUS CHANGE:
FEIN # CHANGE, INDIVIDUAL TO CORPORATION, CORPORATION TO LLC, ETC.)
4. Do you have a contract with a PEO/Leasing organization?
Y
N
IF YOU ANSWERED YES TO ANY OF THE QUESTIONS IN PART C, PROCEED TO PART D
1. Effective Date of Change:
2. Date Last Wages Paid for Account in 3A:
M
M
D
D
Y
Y
M
M
D
D
Y
Y
3. Enter information of Business purchased, New Owner, or PEO:
Employer
P
Name:
A
Trade Name
R
or DBA:
T
Address:
D
Zip:
City:
State:
Contact
Phone:
Person:
PART E.
Name changes for Corporate Entities cannot be updated until you provide certification of the changes from the Office of the
Secretary of State.
Direct questions regarding this form to:
Enter the Name and Phone number of
Signature
Printed Name
the person to contact regarding
information for this account.
Title
Phone Number
I certify that the information on this report is true and correct.
5A Rev 0/08
005A00801
999999920081
File online at:
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