Form Mdes-522 - Employer'S Notice Of Change
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1
2EMPLOYER’S NOTICE OF CHANGE
MINNESOTA DEPARTMENT OF ECONOMIC SECURITY-TAX OFFICE
390 ROBERT ST N
ST PAUL MN
55101-1812
TELEPHONE: (651) 296-6141
FAX: (651) 297-5283
TDD/TTY: (651) 297-3944
INTERNET:
-
UNEMPLOYMENT TAX ACCOUNT NUMBER:
Please enter your current business name and address here:
WRITE CURRENT NAME, COMPLETE MAILING ADDRESS AND UNEMPLOYMENT TAX ACCOUNT # ABOVE, IF NOT PRE-PRINTED.
A. ENTER CHANGES TO NAME / ADDRESS / PHONE
1.
BUSINESS NAME:
2.
PHYSICAL LOCATION OF BUSINESS:
3.
MAILING ADDRESS:
4.
FUTURE MAILING ADDRESS IF NO LONGER
OPERATING IN MN:
5.
PHONE:
B. CHANGES IN BUSINESS STATUS
COMPLETE THOSE SECTIONS WHICH APPLY
IF SALE OR ACQUISITION OF BUSINESS, USE SECTIONS ON BACK OF FORM FOR NOTIFICATION.
1.
BUSINESS STILL OPERATES IN MINNESOTA, BUT WITHOUT MN EMPLOYEES EFFECTIVE: ___ ___ / ___ ___ / ___ ___
EXPLAIN: __________________________________________________________________________________________________
2.
DISCONTINUED ALL OPERATIONS IN MINNESOTA EFFECTIVE: ___ ___ / ___ ___ / ___ ___
BEC
AUSE OF:
LIQUIDATION
DEATH
OTHER (EXPLAIN): _________________________________________________________
DATE OF LAST WAGES PAID FOR MINNESOTA SERVICES: ___ ___ / ___ ___ / ___ ___
3.
CHA
NGED FROM:
CHANGED TO:
!
!
SOLE PROPRIETOR
SOLE PROPRIETOR
!
!
PARTNERSHIP
PARTNERSHIP
!
!
LLC
LLC
!
!
CORPORATION
CORPORATION
!
!
OTHER:
OTHER:
_______________________________________________
______________________________________________
-
FEDERAL I D # (FEIN):
FEDERAL I D # (FEIN):
-
: ___ ___ / ___ ___ / ___ ___
___ ___ / ___ ___ / ___ ___
CHANGED LEGAL ENTITY EFFECTIVE
FIRST MN PAYDAY FOR NEW ENTITY:
4.
USE LEASED EMPLOYEES EFFECTIVE: ___ ___ / ___ ___ / ___ ___
EMPLOYEE LEASING COMPANY: _____________________________________________
PHO
NE: ___________________________
CONTINUED ON OTHER SIDE
MDES-522 (REV.12-00) (SN-02057-06)
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