Form 941bn-Me - Business Change Notification

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Business Change
M
R
S
AINE
EVENUE
ERVICES
F
941BN-ME
ORM
Notifi cation
Complete this form to report a change in your withholding account contact information or to cancel
your withholding or unemployment insurance account. Incomplete forms will not be processed.
Mail to: Maine Dept. of Labor, Central Registration Unit
Fax 207-287-3733
P.O. Box 1057, Augusta, ME 04332-0057
Step 1
Current Name:________________________________________________________________________________
Identify your
Current Address:______________________________________________________________________________
business as
currently on
Current Phone Number:________________________________________________________________________
fi le with Maine
Revenue
Withholding Account Number:_____________________ UC Employer Account Number:_____________________
Services.
Step 2
New Name:__________________________________________________________________________________
List your new
New ATTN Line:______________________________________________________________________________
contact
information;
New Address:________________________________________________________________________________
enter only if
different from
New Email Address:___________________________________________________________________________
(PRINT CLEARLY)
current
/
/
information.
New Phone Number: ___________________________Effective Date of Change__________________________
NOTE: Do not enter a Payroll Preparer’s address or other contact information
here.
Step 3
Check this box to cancel Withholding Account
Request to
Check this box to cancel Unemployment Insurance Contributions Account.
cancel
account.
Reason for Cancellation:
Business Closed
(Do not
report
Business Sold to: Name:______________________________________________
cancellation
for a seasonal
Address:____________________________________________
shutdown
period.)
____________________________________________
/
/
Date Business Sold: __________________________________
Other _____________________________________________________________
Date the business no
/
/
/
/
longer had employees
Date of last payroll
______________________________________
________________________________
Step 4
Under penalties of perjury, I certify that the information contained on this form is true and correct.
Print Name:__________________________________________________________________________________
Sign and
mail your
Signature:_________________________________ Print Title:__________________________________________
report.
/
/
Date: ____________________________________ Daytime Phone: ____________________________________
For Paid Preparers Only
Paid Preparer’s Signature:____________________________________________________
/
/
Date: _____________________________
Phone: ____________________________
Firm’s Name (or yours if self-employed):_________________________________________
Address:_____________________________________________________________________________________________________
EIN/SSN: _______________________________Maine Payroll Processor License Number: ___________________________________
3
Rev. 12/10

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