Michigan Form Uia 1025 – Fill Out and Use This PDF

State of Michigan

Department of Labor & Economic Growth

UIA 1025

UNEMPLOYMENT INSURANCE AGENCY

Authorized by

Tax Office

(Rev. 03-04)

MCL 421.1, et seq.

P.O Box 8068 • Royal Oak, Michigan 48068-8068

www.michigan.gov/uia

Employer Request For Address/Name Change

Current Employer Name: _________________________________________________________________________________

UIA Employer Account No.: _________________________

Federal Employer ID No. (FEIN): ________________________

New Employer Name: ___________________________________________________________________________________

DBA: _________________________________________________________________________________________________

E-Mail Address: ________________________________________________________________________________________

PLEASE DO NOT SUBMIT THIS FORM UNLESS THERE HAS BEEN A CHANGE IN NAME OR ADDRESS.

Physical Location of the Business

Mailing Address

No Post Office boxes, please.

(Include both addresses, even if only one has changed.)

Street:

Street:

City:

City:

State:

Zip Code:

–

State:

Zip Code:

–

E-Mail Address:

E-Mail Address:

Mailing Address is:

Employer's Telephone Number: (

)

Accountant/Employer Rep*

Corporate Office

Owner

*To request a change of mailing address to an employer representative (CPA, Service Bureau, Attorney, etc.) YOU MUST FILE A POWER OF ATTORNEY AUTHORIZATION FORM.

CHANGING ACCOUNT INFORMATION: If you have discontinued or ceased business activity, discontinued employment, sold or transferred ownership of all or part of your business, formed a new partnership or corporation, merged, or changed your status as a sole proprietorship or corporation, you must file a Report of Discontinuance or Disposition of Business, Form UIA 1772.

THE CORRECTION OF A PREVIOUSLY FILED REPORT (UIA 1020) MUST BE MADE ON AN Amended Quarterly Tax Report, Form UIA 1021. Other changes, including FEIN changes or bankruptcy filing, etc., must be submitted in writing with supporting documentation. YOU MUST sign and date this form, giving your title and telephone number, before changes will be accepted.

Preparer: _______________________________________ Title: ___________________________________________

Date: ____________________ Preparer Telephone No.: ( ________ ) _________________________

If you need assistance, telephone 1-800-638-3994, outside Michigan 1-313-456-2180.

Mail this form with your changes to the above address, or fax to (313) 456-2130. If known, indicate your Tax Team ____.

FORMS MAY BE FAXED TO YOU 24 HOURS A DAY BY CALLING: 1-800-638-3994 FORMS CAN ALSO BE OBTAINED ON

OUR WEBSITE: www.michigan.gov/uia.