Employer'S Report On Change Of Ownership - Workforce Development
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1Date Stamp
NEBRASKA WORKFORCE DEVELOPMENT
OFFICIAL USE ONLY
DEPART OF LABOR
Predecessor Liable Number
UNEMPLOYMENT INSURANCE
PO Box 94600
File Locator Number
Lincoln NE 68509-4600
Successor Liable Number
EMPLOYER’S REPORT ON CHANGE OF OWNERSHIP
(To Be Filed by the Predecessor)
Termination Date
Reviewer
1. Did a successor employer acquire your business?
Yes
No
Date successor acquired business :
Name and Address of Successor:
2. Did the successor employer acquire ALL or PART of your business?
ALL
PART
(Acquisition of one of several locations in Nebraska is considered PART of the business)
3. How acquired?
Purchase
Lease
Franchise
Merger
Other (explain)
4. Did the successor acquire the organization or assets of your business?
Yes
No
5. Is the successor serving the same customers and/or offering the same service or product?
Yes
No
6. If the successor acquired only PART of your business, list any place of business owned by you IN NEBRASKA which were not included in the change
of ownership.
Trade Name
Street
City
State
Zip
7. Will you start or acquire another business after the date of sale?
Yes
No
8.Indicate name, address and telephone number to be used for future correspondence, if necessary.
Name
Address
City
State
Zip Code
Phone Number
Signature
Title
Date
If you have any questions or need assistance completing this form, contact our Status Unit at (402) 471-9935 or our Fax number is (402) 471-9994.
UI Form 37 (Revised 9-03)
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