Form Uia 1925 - Request For Name And/or Address Change
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1UIA 1925
State of Michigan
Authorized by
(Rev. 12-2003)
Department of Labor & Economic Growth
MCL 421.1, et seq.
UNEMPLOYMENT INSURANCE AGENCY
REQUEST FOR NAME and/or ADDRESS CHANGE
• FOR A NAME CHANGE REQUEST, SUBMIT A COPY OF LEGAL PROOF WHICH DOCUMENTS THE CHANGE •
Check Appropriate Box:
NAME CHANGE
ADDRESS CHANGE
Your Name: _________________________
________________________________
__________
First
Last
Middle Initial
Social Security Number:
—
—
NAME CHANGE
Your Name: _________________________
________________________________
__________
First
Last
Middle Initial
Reason for Change:
Married
Divorced
Personal Choice
ADDRESS CHANGE
Old Address: __________________________________________________________________________
Street Address
City
State
Zip Code
New Address: _________________________________________________________________________
Street Address
City
State
Zip Code
Telephone Number: ( _______ )
_________________________
Area Code
If you have relocated outside of Michigan, will it be for more than 4 weeks? .......
Yes
No
(If you answered “Yes,” your file will be transferred to the Interstate Benefit Unit.)
I know the law provides penalties of fine and/or imprisonment and/or community service for any false
statement(s). I certify that the information reported on this form is true and correct to the best of my
knowledge.
Your Signature: _______________________________________________
Date: ____________________
RETURN COMPLETED FORM TO: UIA, P.O. BOX 5050, SAGINAW, MI 48605-5050, FAX: (989) 758-1986
• FOR UIA USE ONLY •
DO NOT SIGN UNTIL YOU HAVE ENTERED THE UPDATED INFORMATION INTO THE SYSTEM.
Staffperson’s Signature: ________________________________
Data Entry Date: ______________
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