UC-517 (10-10) ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Unemployment Insurance Administration
Instructions for
Authorization to Change Address
Use this form to change the business’s legal mailing address, the business’s headquarters address and/or the address where the Unemployment Benefit Claim Notice to Employer (UB-110) is to be mailed. An owner, partner, or corporate officer must sign the form authorizing the change.
Use the Report of Changes form (UC-514) to advise the Arizona Department of Economic Security of any modifications to your business structure. Example – Changes in ownership, legal form, operation, or payroll method.
Questions about completing this Authorization to Change Address form may be directed to the Employer Registration Unit at:
Employer Registration Unit
ADES-UI Tax Section – 911B
PO Box 6028
Phoenix, AZ 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, and the Age Discrimination Act of 1975, the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, and disability. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. 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. • Ayuda gratuita con traducciones relacionadas a los servicios de DES está disponible a solicitud del cliente.
UC-517 (10-10) – Page 2 ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Unemployment Insurance Administration
Unemployment Tax Section ( 911B
P.O. Box 6028, Phoenix, AZ 85005-6028
Phone: 602-771-6602 ( Fax: 602-532-5539
www.azuitax.com
Business Name and Current Address of Record
Date:
Employer No.:
AUTHORIZATION TO CHANGE ADDRESS
The undersigned hereby requests that the following change(s) of address be made.
CHANGE IN THE BUSINESS’S LEGAL MAILING ADDRESS
ADDRESS (No., Street, PO Box)
CITY STATE ZIP PHONE NO.
CHANGE IN THE BUSINESS’S LEGAL HEADQUARTERS ADDRESS
ADDRESS (No., Street, PO Box)
CITY STATE ZIP PHONE NO.
CHANGE IN THE BUSINESS’S EMAIL ADDRESS
EMAIL ADDRESS
All correspondence, including the employer’s Unemployment Tax and Wage Report (UC-018), Benefit Charge Notice (UC-602), the annual Determination of Unemployment Tax Rate for Calendar Year (UC-603), and periodic Unemployment Tax Statement (UC-145) forms are to be sent to the business’s legal mailing address. In addition, the Notice to Employer (UB-110) regarding unemployment benefit claims filed against the business will be mailed to the business’s legal mailing address unless otherwise requested below.
MAIL THE NOTICE TO EMPLOYER (UB-110) TO:
ADDRESS (No., Street, PO Box)
CITY STATE ZIP PHONE NO.
AUTHORIZED SIGNATURE
OWNER/PARTNER/CORPORATION OFFICER’S TITLE OWNER/PARTNER/CORPORATION OFFICER’S SIGNATURE
AGENCY USE ONLY
AGENCY USE ONLY NOTATIONS
Revise address
Add UB-110 address
Delete UB-110 Address
Add Phone No.
Revise Phone No.
DATE ENTERED BY INITIALS DATE
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