Fillable Form Ui-50a - Notice Of Change (Page 2 of 2) in pdf

3. REORGANIZATION, SALE OR OTHER ORGANIZATIONAL CHANGE. Check all items that apply to you. If any item in this section is checked, please complete

numbers 4 & 5 below.

___ Sale of enterprise: __ Entirely; __ In part (Explain) _____________________________________________________________________________________________________________

___ Lease of enterprise: __ Entirely; __ In part (Explain) _____________________________________________________________________________________________________________

___Change in type of business structure:

From:

__ Sole Proprietorship:

__ Partnership:

__ Corporation

FEIN ___________________________________________________________

To:

__ Sole Proprietorship:

__ Partnership:

__ Corporation

FEIN ___________________________________________________________

___Partnership reorganization (Explain in detail) _______________________________________________________________________________________________

___Corporate merger, consolidation or reorganization (Explain in detail) _________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________

___ Foreclosure;

__ Receivership;

__ Bankruptcy;

__ Assignment for benefit of creditors

Type __

Date _____/_____/_____

Case Number _____________________________

Death of: __ Owner; __ Partner

Name of deceased ___________________________________________________________________________________

4. IF ANY OF THE ITEMS IN #3 ABOVE ARE CHECKED, FURNISH THE FOLLOWING INFORMATION:

Date of acquisition (or change of business entity; for example, from a sole proprietor to a corporation) _____________________________________________________________

Name of new owner __________________________________________________________________________________________________________________________

Doing business as ____________________________________________________________________________________________________________________________

Illinois U.I. account number (if known) ____________________________________________________ Fed. ID. Number (if known) _________________________

Address: ____________________________________________________________________________________________________________________________________

5. FURNISH THE FOLLOWING INFORMATION WITH RESPECT TO YOUR ILLINOIS OPERATIONS IF YOU DISPOSED OF OR LEASED ONLY A PORTION

OF YOUR BUSINESS ENTERPRISE.

A. Did you operate at more than one location in Illinois? ___________ YES ____________ NO

If YES, list the name and address of the Illinois locations you retained or continued to operate:

Name and Address

City/Town

State

Zip

County

Location 1 ____________________________________________________________________________________________________________________________

Location 2 ____________________________________________________________________________________________________________________________

Location 3 ____________________________________________________________________________________________________________________________

Location 4 ____________________________________________________________________________________________________________________________

Location 5 ____________________________________________________________________________________________________________________________

Location 6 ____________________________________________________________________________________________________________________________

B. Did the new owner(s) acquire all of your Illinois operations? ____ YES ____ NO

If NO, percent of assets of Illinois operations that new owner(s) acquired _____________ %

Percent of assets retained by you __________ %

C. Are the new owners employing all of the same people that you employed on your last day in business? ____ YES ____ NO

If NO, how many people were employed by you? __________

How many of them did the new owner employ? __________

D. If all that remained of your business on the last day it operated was inventory or real property, what percentage of this was acquired by the new owner? _______ %

E. Was the business that was acquired from you a franchise? ____ YES ____ NO

If YES, were you the ____ franchisee or the _____ franchisor?

CERTIFICATION: I HEREBY CERTIFY THAT THE FOREGOING INFORMATION AND THAT CONTAINED IN ANY ATTACHED SHEETS SIGNED BY ME IS

TRUE AND CORRECT, AND THAT I AM AUTHORIZED TO EXECUTE THIS REPORT ON BEHALF OF THE EMPLOYING UNIT NAMED.

BUSINESS NAME _____________________________________________________________________________ DATE SIGNED AND SUBMITTED _____/_____/_____

SIGNED BY ______________________________________________________________________________________ OFFICIAL TITLE _________________________________

HOME ADDRESS OF OFFICIAL ___________________________________________________________________________________________________________________

HOME TELEPHONE NUMBER (________)_________________________________________

THIS REPORT MUST BE SIGNED BY OWNER, PARTNER, OFFICER OR AUTHORIZED AGENT WITHIN THE EMPLOYING ENTERPRISE. IF SIGNED BY ANY OTHER

PERSON, A POWER OF ATTORNEY MUST BE ATTACHED.

This state agency is requesting information that is necessary to accomplish the statutory purpose as outlined under 820 ILCS 405/100-3200. Disclosure of this information is REQUIRED. Failure to

disclose this information may result in statutorily prescribed liability and sanction, including penalties and/or interest.