UC-514 (10-17)            ARIZONA DEPARTMENT OF ECONOMIC SECURITY
                                        Employer Engagement Administration

                                   REPORT OF CHANGES FORM

The Report of Changes form is used to advise the Arizona Department of Economic Security of any modifications to 
your businessOPERATION or STRUCTURE. You must promptly report any changes inOWNERSHIP,LEGAL FORM                  , 
OPERATION,PAYROLL METHOD           , or ADDRESS of your business. Failure to do so may result in additional costs to 
you later.

Your completed form should be mailed or faxed to the address or fax number shown below.

Questions about completing the Report of Changes form or how modifications to your business may affect your UI tax 
account should be directed to the Employer Registration Unit at:

                                        Employer Registration Unit 
                                        P.O. Box 6028 • Mail Drop 5881 
                                        Phoenix, Arizona 85005-6028 
                                        Telephone: (602) 771-6602 
                                        Fax:(602)532-5539 
                                        Email uitstatus@azdes.gov

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the 
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination 
Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits 
discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national 
origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a 
person with a disability to take part in a program, service, or activity.  Auxiliary aids and services are available upon 
request to individuals with disabilities.  To request this document in alternative format or for further information about 
this policy, Contact the UI Tax Office at 602-771-6606; TTY/TDD Services: 7-1-1. • Free language assistance for DES 
services is available upon request.

   ARIZONA DEPARTMENT OF ECONOMIC SECURITY                                                                             UC-514 (10-17)
                                                                               REPORT OF CHANGES
P.O. Box 6028 • Mail Drop 5881 • Phoenix, AZ 85005-6028                        ARIZONA ACCOUNT NUMBER
        Telephone (602) 771-6602 • Fax (602) 532 5539

Report ANY CHANGES PROMPTLY (ownership, legal form, operation, payroll         FEDERAL ID NUMBER
method, or address of your business) as required by Arizona Administrative 
Code R6-3-1703. Failure to do so could result in additional cost to you later.:

A.      Change in Mailing Address
NEW ADDRESS   (No., Street, or P.O. Box)                                       MAIL NOTICE OF UNEMPLOYMENT CLAIMS TO (No., Street, or P.O. Box)

CITY, STATE, ZIP CODE                                                          CITY, STATE, ZIP CODE

PHONE NUMBER                                                                   PHONE NUMBER   
B.      Change in the Business’ Email Address                                  Change in Sides E-Response Email Address

EMAIL                                                                          EMAIL
C.      Change in Arizona Ownership / Operation
   All of the Arizona business was transferred to(complete item 1 below), as of                                         (date)
   Part of the Arizona business was transferred to (complete items 1 and 2 below), as of                                (date)
   In the portion of business transferred, did you during the current or preceding calendar year: 1) Employ one or more 
   individuals for a part of a day in at least 20 weeks, or pay $1,500 or more in wages in a calendar quarter, OR 2) If the 
   business is agricultural, did you employ 10 or more individuals for a part of a day in at least 20 weeks, or pay $20,000 
   or more wages in a calendar quarter?   Yes                    No
    No ownership change occurred, but payroll is paid by (complete item 1 below), as of                                 (date)
   No ownership change occurred, but leasing employees (complete item 1 below), as of                                   (date)
   AZ Business was discontinued without being sold, leased or transferred, as of                                        (date)
   Business is operating in Arizona, but ceased paying wages, as of                                                     (date)
ITEM 1  NAME OF NEW OWNER, PARTNERSHIP, CORPORATION, PAYROLLER, LEASING COMPANY                     PHONE NUMBER 

        ADDRESS (No., Street, P.O. Box, City, State, ZIP Code)                                      ARIZONA ACCOUNT NUMBER

ITEM 2  NAME OF BUSINESS YOU RETAINED                                                               PHONE NUMBER 

        ADDRESS (No., Street, P.O. Box, City, State, ZIP Code) 

D.      SIGNATURE AND TITLE OF OWNER, PARTNER, CORPORATE OFFICER OR AGENT                           DATE

        MAILING OR FORWARDING ADDRESS (No., Street, P.O. Box, City, State, ZIP Code)                PHONE NUMBER 

                                               FOR AGENCY USE ONLY
  Change of owner                               Inactive                             Comments
  Merge into                                    Suspend 
  Transfer to                                    Established in Error 
   Revise close code                            Terminate 
  Close date 
Initial    Date
                                         See reverse for EOE/ADA/LEP/GINA disclosures