Form Uct-6491 - Account Changes - Report Employment And Business Changes

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ACCOUNT CHANGES - REPORT EMPLOYMENT AND BUSINESS CHANGES
This form must be completed and returned if changes have
Return completed form to:
occurred to this business. If there have been no changes, do not
DWD Unemployment Insurance Division
return the form.
Bureau of Tax and Accounting
P O Box 7942
Please contact us if you have questions:
Madison WI 53707
608-261-6700
Fax:
608-267-1400
taxnet@dwd.wisconsin.gov
Email:
taxnet@dwd.wisconsin.gov
UI Account Number
Legal Name
A. REQUIRED: CONTACT INFORMATION:
Information supplied by (name and position)
Date Form was Completed
/
/
Phone Number
Email Address
(
)
Person to contact for additional information (name and position)
Phone Number
Email Address
(
)
B. ENTER CHANGES FOR LISTED ITEMS OR COMPLETE IF ANY ITEM IS BLANK ON YOUR CONTRIBUTION/WAGE REPORT:
New Address
New Legal Name
New Trade Name
New Business Email Address
New Federal ID Number
New Phone Number
(
)
C. COMPLETE IF BUSINESS WILL NOT HAVE EMPLOYEES DURING THE NEXT 12 MONTHS OR LONGER:
Date of Last Wisconsin Employment
Business activity ended (business not sold)
/
/
Sale/transfer/reorganization of business activity/assets (complete Section D below)
No longer operating in Wisconsin, but still operating in another state
Date of Last Wisconsin Payroll
Business continuing without employees (provide explanation in Section E below)
/
/
Employing Independent Contractors
Death
______________________________________
Other:
D. SALE/TRANSFER/REORGANIZATION OF BUSINESS: Section 108.16(8)(k) Wis. Stats. Requires Written Notice Within 30 Days Of Change
Date of Reorganization
Does the reorganized business have different
ownership than the former business?
Yes
No
/
/
Change in
New Federal ID Number
Briefly explain the reorganization
Business Entity/
Reorganization
New Legal Name
New Address
Transferred/
Transfer Effective Date
Check One:
Sold or
/
/
Total Sale
Partial Sale
Total Purchase
Partial Purchase
Acquired
Legal Name
Check One:
Business
Business Sold/Transferred to
Trade Name
Business Acquired From
UI Account Number
Address
Phone Number
(
)
E. OTHER CHANGES (PROVIDE EXPLANATION):
UCT-6491 (R. 05/2017)

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