Form Nucs-4074 - Employer'S Report Of Changes

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State of Nevada
Department of Employment, Training & Rehabilitation
EMPLOYMENT SECURITY DIVISION
500 E. Third Street, Carson City, Nevada 89713-0030
Fax: 775-684-6329
Telephone: 775-684-6310
Web Site:
EMPLOYER'S REPORT OF CHANGES
Please indicate the changes that apply, sign and date, then return by mail or fax as stated above:
EMPLOYER: ________________________________________ EMPLOYER ACCOUNT NUMBER: ________________
Change Mailing Address or Name of Business To:
Business Discontinued (no new ownership).............................................................................
(Please notify the Division if, or when, business resumes.)
Month/Day/Year
Exact Date of Last Payroll
___________________
Month/Day/Year
Change in Business Ownership - Complete NEW OWNER(S) section below.
Sale of Entire Business.................................................................................................
Month/Day/Year
Partial Sale (not out of business)
Month/Day/Year
.................................................................................
Describe Part Sold
Change in Legal Ownership........................................................................................
Month/Day/Year
(such as adding or dropping a partner, incorporating, etc.)
NEW OWNER(S)
New Federal Identification Number (if applicable):
Check Type of Organization:
S Corporation
Sole Proprietor
Limited Liability Partnership
Publicly Traded Corporation
Association
Limited Liability Company
Privately Held Corporation
Partnership
Other
Name and address of new owner(s), partner(s), corporate officer(s), member(s), etc. ___________________________
Remarks
New Business Units Added to Present Ownership......................................................................
Month/Day/Year
Trade Name__________________________________________________________________________________
Location_____________________________________________________________________________________
Nature of Operation____________________________________________________________________________
Previous Owner(s)_____________________________________________________________________________
Signature & Title______________________________________Telephone No._________________ Date___________
NUCS-4074 (10/12)

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