Mississippi Department of Employment Security 
                                          P.O. Box 22781 
                                          Jackson, MS  39225-2781 

        EMPLOYER’S QUARTERLY WAGE AND CONTRIBUTIONS REPORT 
               EMPLOYER CHANGE REQUEST 

Complete this form ONLY if your name, address, federal ID No., ownership or business has changed. 

Please enter the following REQUIRED information before filling out this form. 
Name:__________________________________________ 
E-mail address:___________________________________ 

If there have been no changes, DO NOT submit this form for processing. 

Reporting Employer’s MDES Account No.        Reporting Employer’s Name and Address (as it appears 
_____________________________________    on your last Quarterly Contribution Report) 
                                                                             _____________________________________________ 
                                                                             _____________________________________________ 
                                                                             _____________________________________________ 
                                                                             _____________________________________________ 

1.  If your name or address is incorrect or has     3. If you have discontinued your business, ceased having  
changed from that shown on your last quarterly  employment, or had a change in ownership, please  
contribution report, enter corrections or            indicate changes below: 
change below:  
______________________________________                                                           Date
______________________________________  No more employees after:                      _______________
______________________________________  Business discontinued:                        _______________
______________________________________  Entire business sold:                         _______________
______________________________________  Partial sale only, not out of business:_______________
______________________________________  Corporation formed:                           _______________
                                                                              Merger: _______________
2.  If your Federal Identification Number is         Partners added or withdrawn:     _______________
different from that shown on your last                Other:  Explain-________________________________ 
Quarterly Summary Report, enter your                _____________________________________________ 
correct number here:                                             _____________________________________________ 
______________________________________  _____________________________________________ 

                                                                              New owner’s name, address, and telephone number: 
                                                                              _____________________________________________ 
                                                                              _____________________________________________ 
                                                                              _____________________________________________ 
                                                                              _____________________________________________ 
                                                                              _____________________________________________ 
I certify that this information is true and correct to the best of my knowledge and belief. 

__________________________________________     _________________________________ 
 Authorized Representative (please type)  Date

__________________________________________     __________________________________ 
  Title                                   Telephone Number (including area code)