Employer's Notice of Change 
60-0111 (07-16)  
  
Unemployment Insurance Tax Bureau 
1000 E Grand Ave 
Des Moines IA  50319-0209                                                                                          Use this form to report changes in account information. 
Phone: 888-848-7442                                                                                                    Attach any documentation you feel is necessary.

UI Account #:                                  Legal Business Name:
                                               If your Legal Entity Type or Federal Identification Number (FEIN) has changed for any reason,  
Business Information Change                    complete the "Change in Ownership" section below or attach a letter.
  Legal Business                                                                                Legal Entity Type 
  Name Changed to:                                                                                    Changed to:

  DBA Changed to:
Address Information Change                     Select the address(es) you are changing and provide the new information.  
                                               If you added locations, attach a list providing the full name, address and phone number of each location.
  Primary Address       Mailing Address        Reporting Unit #:                                Primary Address        Mailing Address Reporting Unit #:
  Address 1:                                                                                    Address 1:
  Address 2:                                                                                    Address 2:
  City:                                        State:                                           City:                                                   State:
  Zip+4/Postal:                                Phone:                                           Zip+4/Postal Code:                     Phone:

Inactivate Account Request
  Reason:         Business closed (If sold or transferred, complete the "Change of Owner" section below.)
                        Date business closed:                                            Date last wages were paid:
                  Operating without employees in Iowa (Corporate officer salaries ARE wages and ARE taxable.)          Date last wages were paid:

  Bankruptcy Information - If your business has filed for bankruptcy, complete the information below.
  Bankruptcy Court:                                                                             Attorney Name:
  Chapter Number:                               Type of Bankruptcy:                             Address:
  Case Number:                                         Personal                                 City:                                                   State:
  Petition (File) Date:                                Business                                 Zip+4/Postal Code:                     Phone:

Ownership Change - Includes Sale, Assumption, Merger, Transfer, Lease
  Provide future address information in the Address Information Change section above. 
  Reason:         Sold, merged, leased or transferred PART of Iowa business                     Sold, assumed, merged, leased or transferred ALL of Iowa business
  Portion of Iowa business sold, merged, leased or transferred:
                                                                                                Legal date of transfer:
                                                                                         Date last wages were paid:
                                                                                         Does the business continue to generate Iowa payroll?    Yes    No
  New Ownership Information - Provide the following information about the new owner, if known.
    Owner Name:                                                                                                Contact Person:
       Address 1:                                                                                               Contact Phone:
  Address 2:
       City:                         State:            Zip+4/Postal:

I certify that the information in this notice is complete and correct. If my account is inactive, I will notify Iowa Workforce Development immediately if employment in 
Iowa is resumed.
  Signature:                                                                             Title: 

  Print Name:                                                                            Phone:                          Date:
NOTE: Information collected from employers by the Unemployment Insurance Services Division of Iowa Workforce Development may also be 
provided to various federal and state agencies as required or permitted by federal and state law. 
  Equal Opportunity Employer/Program 
  Auxiliary aids & services are available upon request to individuals with disabilities. 
  For deaf and hard of hearing, use Relay 711.