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      DWD Unemployment Insurance Division 
not return the form.                                               Bureau of Tax and Accounting 
                                                                   P O Box 7942 
Please contact us if you have questions:                           Madison WI 53707-7942 
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.  ENTER APPROPRIATE INFORMATION ON ANY CHANGE IN YOUR BUSINESS OPERATIONS: 
                   Out of Business/Liquidation (business not sold)                                      Date of Last Payroll 
                   Sale/ transfer/reorganization of business activity/assets (complete Section D below) 
Closed             Business continuing without employees (provide explanation in Section E below) 
Business           Employing Independent Contractors                                                    Date of Last Employment 
                   Death 
                   Other:_______________________________ 
                   No employees – a temporary situation                                                 Date of Last Employment 
No                Explanation: 
Employment  
This Quarter                                                                                            Approximate Date Employment will Resume 

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. 11/2012)