NCUI101-A-I-ChangeinStatusReport-EmploymentSecurity.doc

CHANGE IN STATUS REPORT Account Number Employer Name and Address: Return to: NC Dept. of Commerce Division of Employment Security P.O. Box 26504 Raleigh, NC 27611-6504 Nature of Change Please check as appropriate A. Sold or otherwise transferred all or part of the business to: Employer Name: Date of Sale: Trade Name: Phone: - Address: Was the entire business operation and all its incidents including equipment, merchandise, raw materials sold, transferred, or leased to new owner? Yes No B. Partnership formed or changed. Explain including effective date : C. Incorporated business Effective date : D. Ceased operations in North Carolina. Date operations ceased: E. Operating without employees. Last date of employment: F. Changed business name to: If corporation, furnish copy of corporate minutes or amended charter on file with the Secretary of State G. Changed: Business Location Mailing Address Telephone Number New Address: - Street Telephone Number City State Zip Code H. Change in person to contact for tax matters: Name Address - Phone Number For Agency Use Only Signature of person authorizing change Action Taken Operator Date NCUI 101-A Rev. 09/2013