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: 
                                                                                    Date of 
   Employer Name:                                                                   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)