EMPLOYER CHANGE NOTICE

 Mail to: New Hampshire Employment Security,  Attn: Status Unit,  45 South Fruit Street,  Concord, NH 03301,  or  FAX to 603-225-4323
 NAME AND ADDRESS                                                                                   STATE EMPLOYER  
                                                                                                  ACCOUNT NUMBER

  CHANGE IN FEDERAL IDENTIFICATION NO.,                                                                                     CHANGE IN OWNERSHIP
                      NAME AND/OR ADDRESS                                                           □  CHANGE IN OWNERSHIP                        □  SOLD BUSINESS
FEDERAL IDENTIFICATION NUMBER CHANGED TO:     ___ ___   – ___ ___ ___ ___ ___ ___ ___                __________________________                   ___________________________
                                                                                                        DATE                                              DATE
BUSINESS NAME CHANGED TO:    ______________________________________________________
                                                                                                 BUSINESS SOLD TO:    _________________________________________________________________
 IF YOU RECEIVE A NEW FEIN, YOU WILL NEED TO REGISTER FOR A NEW UI ACCOUNT                       ADDRESS:
BUSINESS LOCATION CHANGED TO:                                                                         __________________________________________________________________________________
   __________________________________________________________________________________                 __________________________________________________________________________________
   __________________________________________________________________________________            DATE SOLD:  _________________________________ % OF ASSETS SOLD:   ________________
MAILING ADDRESS CHANGED TO:
                                                                                                 NEW OWNERS UI ACCOUNT NUMBER OR FEIN:   _________________________________________
   __________________________________________________________________________________
                                                                                                 ARE THESE TWO COMMONLY OWNED COMPANIES?                      □  YES □  NO 
   __________________________________________________________________________________
                                                                                                 CHANGED BUSINESS STRUCTURE ON:   _________________________________________________
  REQUEST TERMINATION OF ACCOUNT BECAUSE                                                                                           DATE
                                                                                                 CHANGE IN BUSINESS STRUCTURE (PLEASE CIRCLE):
□ BUSINESS CONTINUES, NO LONGER FURNISHING EMPLOYMENT IN NH
                                                                                                    FROM      1 SOLE PROPRIETOR                TO         1   SOLE PROPRIETOR
  PLEASE EXPLAIN:     ________________________________________________________________                        2 LLC, SINGLE MEMBER                        2   LLC, SINGLE MEMBER
□ LAST DATE OF NH WORK PERFORMED:               _______________________________                               3 LLC, MULTI MEMBER                         3   LLC, MULTI MEMBER
                                                DATE                                                          4 CORPORATION                               4   CORPORATION
□ LAST DATE OF NH PAYROLL:                      _______________________________
                                                DATE
  * BUSINESSES THAT FILE WITH THE IRS AS S-CORPS ARE ALSO CONSIDERED                                ** PROVIDE INFORMATION BELOW - SIGNATURE REQUIRED **
  CORPORATIONS WITH NEW HAMPSHIRE EMPLOYMENT SECURITY (NHES)
                                                                                                 F NAME:   _________________________________________________________________________
                                                                                                                PLEASE PRINT
                                                                                                     ____________________________________________________      __________________________
                                                                                                    TELEPHONE                                                 DATE
                                                                                                     ___________________________________________________________________________________
                                                                                                    AUTHORIZED SIGNATURE

                                                                                                    To register for a NEW account, visit:                         Save & Submit
                                                                                                    www2.nhes.nh.gov/empstatus/