Transfer Term Pending
For Departmental Use
IOWA WORKFORCE DEVELOPMENT
Attn: Tax Bureau
1000 East Grand Avenue
Des Moines, Iowa 50319-0209
EMPLOYER'S NOTICE OF CHANGE
Use this document to record a change of address, change of name, change of telephone number, addition or change of federal ID number, change
of account status, cessation of business or sale of a portion or all of the Iowa business. If not preprinted, provide your employer name and account
number. Complete all sections that apply, then date and sign below. Attach any documentation you feel is necessary.
Iowa Account Number
CORRECTIONS OR CHANGES TO EXISTING ACCOUNT INFORMATION:
Mark appropriate choice and provide additional information requested
Mailing address changed to
Effective date of change
Legal name changed to
Telephone number changed to
Location address changed to
Business name changed to
If Federal IRS/employer identification (FEIN) has changed for any reason,
complete "Change In Ownership" section below or attach a letter.
Additional Iowa location(s) added (attach list providing full name
and address of each location)
REQUEST ACCOUNT BE PLACED IN INACTIVE STATUS:
Mark appropriate choice and provide any dates requested.
NOTE that this response pertains to Iowa business activity only.
Closed business. Date last wages paid __________________
(Note: If sold or transferred, complete "Change In Ownership" section below.)
Operating without employees in Iowa.
Attorney telephone number (include area code)
Date last Iowa wages paid ___________________________
(Note: corporate officer salaries are wages and are taxable.)
Attorney name & address
Discontinued household/domestic employment.
Date last wages paid ___________________________________
CHANGE IN OWNERSHIP - INCLUDES SALE, MERGER, TRANSFER, LEASE:
Mark appropriate choice and provide additional information requested. Provide future address in "Corrections or Changes . . . . . " section.
Date of transfer
Prior owner's last date of payroll
Sold, merged, leased or transferred PART of Iowa business
Sold, merged, leased or transferred ALL of Iowa business
New owner name & address
Portion of Iowa business sold, merged, leased or transferred (identify
location(s) and primary assets transferred)
New owner contact person
New owner telephone number
Prior owner retains some Iowa business
which continues to generate Iowa payroll? ..
I hereby certify
that the information in this notice is complete and correct. If my account is in an inactive status, I understand and agree to
notify Iowa Workforce Development immediately if employment in Iowa is resumed.
Signature _______________________________________ Title ___________________ Telephone # ____ ___________________ Date ___________
If you have questions, please call 515-281-3823, 515-281-7298, or 515-281-8217
This form is available at no cost to the public from Iowa Workforce Development