Assigned Account Number                 Please Detach Before Mailing                     Completed forms, inquiries, or corrections  to the individual 
                                                                                                    information contained in this form shall be sent to the TWC 
                                                  STATUS CHANGE FORM                                Tax Department,  PO Box  149037, Austin,  TX   78714-9037, 
                                                                                                    (512) 463-2699. Individuals may receive and review 
                                                                                                    information that TWC collects about the individual  by 
                                                                                                    emailing to  open.records@twc.state.tx.us  or writing to TWC 
                                                                                                    Open Records, 101 E. 15th St., Rm. 266, Austin, TX  78778-
                                                                                                    0001.  
 
                                                                                       Telephone Number                                 Federal ID Number 
                                     Enter Corrections(if needed)                                                                       
 
If your business or employment has been discontinued, if ownership, name or address has changed, if your account number, Federal ID number or telephone number has 
been omitted or is incorrect on your preprinted form, please fill in your account number, enter your corrections and return this page with your tax report. 
 
Name:                                                                                 If your business was acquired by a successor, complete the following: 
                                                                                       
Trade Name:                                                                            
                                                                                      Successor Name:                                                                            
Address:                                                                               
 
Claim Notification Designated Address:                                                Successor Address:                                                                         
                                                                                       
Special Address for Chargeback Summary:                                               Successor Account Number:                                                                  
                                                                                       
                                                                                      Was all or part of the business acquired?         All                  Part                
If you have discontinued employment, complete the appropriate items below:             
           Business discontinued, no successor                                        Which part was acquired?                                                                   
                                                                                       
           Business continued without employment                                                                                                                                 
                                                                                       
           Business acquired by a successor                                           Signature                                   Date                                           
 
Enter the date of acquisition:                                              
 
Date of last employment:                                                    
 
Date final wages paid:                                                      
 
C3SCF (052013)