ACCOUNT CHANGES - REPORT EMPLOYMENT AND BUSINESS CHANGES 
This form must be completed and returned if changes have                 Return completed form to: 
occurred to this business.  If there have been no changes, do not        DWD Unemployment Insurance Division 
return the form.                                                         Bureau of Tax and Accounting 
                                                                         P O Box 7942 
Please contact us if you have questions:                                 Madison WI 53707 
608-261-6700                                                             Fax:   608-267-1400 
taxnet@dwd.wisconsin.gov                                                 Email: taxnet@dwd.wisconsin.gov  
                                                                                 
UI Account Number                                     Legal Name 
                                                       
A.  REQUIRED: CONTACT INFORMATION: 
Information supplied by (name and position)                                                  Date Form was Completed 
                                                                                                       /           /           
Phone Number                                                                                 Email Address 
(          )                                                                                  
Person to contact for additional information (name and position) 
 
Phone Number                                                                                 Email Address 
(          )                                                                                  
B.  ENTER CHANGES FOR LISTED ITEMS OR COMPLETE IF ANY ITEM IS BLANK ON YOUR CONTRIBUTION/WAGE REPORT: 
New Address                                                       New Legal Name 
                                                                   
                                                                  New Trade Name 
                                                                   
New Business Email Address                                        New Federal ID Number                     New Phone Number 
                                                                                                            (         ) 
C.  COMPLETE IF BUSINESS WILL NOT HAVE EMPLOYEES DURING THE NEXT 12 MONTHS OR LONGER: 
  Business activity ended (business not sold)                                                               Date of Last Wisconsin Employment 
  Sale/transfer/reorganization of business activity/assets (complete Section D below)                                 /           /           
  No longer operating in Wisconsin, but still operating in another state                                    Date of Last Wisconsin Payroll 
  Business continuing without employees (provide explanation in Section E below) 
  Employing Independent Contractors                                                                                   /           /           
  Death 
  Other:  ______________________________________ 
D.  SALE/TRANSFER/REORGANIZATION OF BUSINESS: Section 108.16(8)(k) Wis. Stats. Requires Written Notice Within 30 Days Of Change 
                   Does the reorganized business have different           Date of Reorganization 
                   ownership than the former business?  Yes         No              /           /           
Change in  
Business Entity/   Briefly explain the reorganization                     New Federal ID Number 
Reorganization                                                             
                                                                          New Legal Name 
                                                                           
                                                                          New Address 
                                                                           
Transferred/       Transfer Effective Date                                Check One: 
Sold or                      /           /                                     Total Sale  Partial Sale       Total Purchase                   Partial Purchase 
Acquired 
Business           Check One:                                             Legal Name 
                        Business Sold/Transferred to                       
                        Business Acquired From                            Trade Name 
                                                                           
                   UI Account Number                                      Address 
                                                                           
                   Phone Number  
                   (          ) 
E.  OTHER CHANGES (PROVIDE EXPLANATION): 
 
UCT-6491 (R. 05/2017)