The Employer'S Report Of Change Form
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1RETURN TO:
LOUISIANA DEPARTMENT OF LABOR
OFFICE OF REGULATORY SERVICES
IF YOU HAVE QUESTIONS REGARDING THIS FORM, CALL:
P.O. BOX 94050
Employer Status Unit at (225) 342 - 2944
BATON ROUGE, LA 70804-9050
INSTRUCTIONS FOR THE EMPLOYER'S REPORT OF CHANGE FORM
1. Please provide correct information for only those items which have changed or require updating for the first time.
2. Corporations with only a name change and NO OWNERSHIP CHANGE must attach a copy of certification from the
Secretary of State's Office.
3. In the check boxes A to H indicate with an (X) any changes that may have occurred within your business and give
effective date of change.
4. Companies with stock transfers and/or changes in officers with NO OWNERSHIP CHANGE must attach documentation
indicating charter number and a list of new officers.
5. Companies which have SOLD PART OR ALL of their business must attach documentation indicating date and portion
sold as well as name, address, and phone number of other company involved from BILL OF SALE.
6. Companies which have CONTRACTED SOME OR ALL of their employees through a leasing company must attach
documentation indicating date and number of employees contracted as well as name, address, and phone number of
the leasing company.
This form may be filled out on-line.
EMPLOYER'S REPORT OF CHANGE FORM
1. STATE ID NUMBER
2. EMPLOYER NAME CHANGE
CHECK BOX IF ACCOUNT NUMBER
3. DBA NAME CHANGE
HAS BEEN APPLIED FOR
4. PHYSICAL LOCATION CHANGE
5. MAILING ADDRESS CHANGE
6. FEDERAL ID NUMBER CORRECTION
7. REVENUE ID NUMBER CORRECTION
8. BUSINESS PHONE CORRECTION
9. E-MAIL ADDRESS CORRECTION
10. BUSINESS FAX NO. CORRECTION
MARK AN (X) NEXT TO ANY ITEMS BELOW THAT APPLY TO THIS BUSINESS AND GIVE EFFECTIVE DATE OF CHANGE PLUS
ATTACH ANY REQUIRED DOCUMENTATION AS INSTRUCTED ABOVE..
A
Business closed in Louisiana (No ownership change)
Effective Date of Change
B
Stock Transfer (No ownership change)
Effective Date of Change
C
Change in officers (No ownership change)
Effective Date of Change
D
Sold part of this business
Effective Date of Change
E
Sold all of this business
Effective Date of Change
F
Contracted some employees through a leasing company
Effective Date of Change
G
Contracted all employees through a leasing company
Effective Date of Change
H
Contracted with an agent who submits your tax reports
Effective Date of Change
(Attach power of attorney)
INDICATE BELOW THE NAME AND PHONE NUMBER OF THE PERSON TO CONTACT CONCERNING THE CORRECTIONS NOTED ABOVE.
Signature:
Printed Name:
Title:
Phone:
Date:
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Parent category: Business