Form Uia 1772 - Discontinuance Or Disposition Of Business Or Assets

UIA 1772 (Rev. 3-04)

Reverse Side

Complete questions 7 and 8 only if they apply to you. If not, disregard and sign at the bottom.

7. Who acquired the Michigan assets, Michigan organization, Michigan trade, or Michigan business disposed of? (“Acquired” as used

herein refers not only to assets purchased, but includes assets acquired by rental, lease, inheritance, merger, mortgage, foreclosure,

gift, or other transfer. If more than one individual or organization is involved, answer all parts of this question for each purchaser, using

separate sheets. If preferred, additional forms will be supplied upon request).

_____________________________________________

_______________________________________

__________________________

NAME(S)

ADDRESS(ES)

TELEPHONE

a. What percent of the total assets of all your Michigan businesses was acquired by the above? _________%

(Attach a list of any of your Michigan business assets which were not acquired by the above.)

b. What was the reasonable value of the Michigan organization,

Michigan trade, Michigan business or Michigan assets acquired? ................................

$ ____________________________

c. Did the above acquire any part of your Michigan organization (employees)? ...............

All

Part

None

d. Did the above acquire any part of your Michigan trade (customers/accounts)? ...........

All

Part

None

e. Did the above acquire any part of your Michigan business (products/services)? .........

All

Part

None

f. Is the above conducting the Michigan business(es) acquired from you? ......................

All

Part

None

g. Is the above substantially owned or controlled, in whole or in major part, either

directly or indirectly by legally enforceable means or otherwise, by the same interest

or interests which owned or controlled your Michigan business at the time of transfer? .....

All

Part

None

h. Did the above hold any security interest on any of the Michigan assets

acquired from you? .........................................................................................................

All

Part

None

If Yes, indicate balance owed ..........................................................................................

$ ____________________________

8. Purchaser’s/Successor FEIN a.________________________ b. UIA Account #____________________________

Upon discontinuance, disposition or transfer of all of your Michigan business, taxes become immediately due and payable, and

your final Quarterly Tax Report must be filed within 15 days of such date.

TERMINATION OF COVERAGE WHERE TOTAL TRANSFER OF MICHIGAN BUSINESS IS INVOLVED. If you disposed of your

Michigan business and the Agency finds that a total of your experience account is in order, your coverage will be terminated as

of the transfer date. HOWEVER, should you have persons in your employ subsequent to the date on which your Michigan

business was transferred, you are required to notify this Agency immediately because you may be liable for taxes on your

payroll regardless of the number of individuals in your employ.

DISCONTINUANCE OR PARTIAL TRANSFER OF MICHIGAN BUSINESS DOES NOT TERMINATE YOUR COVERAGE. Even

though you may have disposed of a part, or all of your Michigan business in separate parcels, or discontinued all Michigan

operations, you are required to continue to report and pay taxes on any wages paid to Michigan workers whom you may employ

until such time as your coverage is legally terminated.

As prescribed in Rule 115, any and all documents, agreements or records describing the transactions by which all or part of this

Michigan business was disposed of as indicated in Items 5 and 8 above, should be kept available for examination by this Agency or

its duly authorized representative(s) whenever such review is deemed by the Agency to be necessary to a proper administration of the

Michigan Employment Security Act.

CERTIFICATE OF CORRECTNESS

I CERTIFY THAT THE INFORMATION CONTAINED IN THIS REPORT IS TRUE TO THE BEST OF MY KNOWLEDGE.

Date ___________________________________

Name ________________________________________________________________________

(Signature)

__________________________________________________________

(Phone Number w/Area Code of Person Signing This Report)

(Official Position)

Return this form to the address on the front or fax to 313/456-2130.

Form Uia 1772 - Discontinuance Or Disposition Of Business Or Assets - 2004 Page 2

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