Form Uia 1772 - Discontinuance Or Transfer Of Payroll Or Assets In Whole Part

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UIA 1772

Authorized by

STATE OF MICHIGAN

(Rev. 07-15)

MCL 421.1 et seq.

TALENT INVESTMENT AGENCY

Unemployment Insurance

RICK SNYDER

RESET FORM

WANDA STOKES

Michelle Beebe, Senior Deputy Director

GOVERNOR

TIA DIRECTOR

3024 W. Grand Blvd., Detroit, MI 48202

Discontinuance or Transfer of Payroll or Assets in Whole or Part

Information shown on this report is used to determine termination of liability under Section 24 of the Michigan Employment

Security (MES) Act. Completion of this report is required even though you may not be currently employing any workers.

Failure to provide this information may result in a determination being made based on information available to the Agency.

Penalties may be imposed under Section 54(a) or 54(b) of the MES Act for an intentional failure to comply with State law.

Employee Leasing companies must complete a separate Form UIA 1772 for each client entity

terminating its contract.

PART I: EMPLOYER INFORMATION

1. Name and Address used prior to discontinuance or transfer of payroll or assets in whole or part.

a. Name: ___________________________________ Employer Account Number (EAN): ____________

b. Business Address: ___________________________________________________________________

c. Telephone: __________________________

Federal Employer ID (FEIN): _________________

2. Current name and address used since discontinuance or transfer of payroll or assets in whole or part.

a. Name:_________________________________________________

b. Business Address:___________________________________________________________________

c. Telephone: __________________________

3. Provide the following information concerning the owner(s), partners, corporate officers, LLC

member(s), etc., of the organization and the person(s) who safeguard the company’s books and

records. If necessary, please attach additional pages to provide information on all owners.

a. Name: _________________________________ SSN: _________________ Birth Date: ____________