Form Uia 1471-L - Protest Of A (Re)determination (Status)

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UIA 1471-L
Authorized by
(Rev. 6-11)
MCL 421.1, et seq.
State of Michigan
Department of Licensing and Regulatory Affairs
UNEMPLOYMENT INSURANCE AGENCY
Tax Office
P.O. Box 8068 - Royal Oak, Michigan 48068-8068
PHONE: (313) 456-2180 FAX: (313) 456-2131
Print Form
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PROTEST OF A (RE)DETERMINATION (STATUS)
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Employer: ___________________________ UIA Employer Account Number:
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Street Address: ___________________________________________________________________________
City, State, Zip Code: ______________________________________________________________________
I wish to protest the Determination Mailed on: __________________________________________
I wish to appeal the Redetermination mailed on: _________________________________________
Please select the issue PROTESTED/APPEALED below:
Date of Liability
Incorrect FEIN
Localization
Successorship
Wages
Services
Seasonal Status
Termination of Account
Captive Provider
Liability Status
Employer Leasing Company
Other: _____________________________________________________________________________
Please provide the reason(s) for the Protest or Appeal. Attach any additional pages and supporting
documents. See reverse side for detailed instructions. Retain a copy for your records.
YOUR CERTIFICATION: I declare that I have examined this report, and to the best of my knowledge and
belief, it is true, correct and complete.
Signature: __________________________________________ Date: _______________________________
Print Name: _________________________________________ Telephone: (
)
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Title: _______________________________________________
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*1471L1106
LARA is an Equal Opportunity Employer/Program.

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