ARKANSAS DEPARTMENT OF WORKFORCE SERVICES
                       NOTIFICATION OF CHANGE IN STATUS
    USE THIS FORM TO REFLECT ANY CHANGES IN YOUR ACCOUNT
	
	 DWS	ID	Number	___________________________	     FEDERAL	ID	NUMBER	___________________

	 EMPLOYER	NAME	______________________________________________________________________

IF	THERE	HAS	BEEN	AN	OWNERSHIP,	ADDRESS	OR	OTHER	CHANGE	MADE	REGARDING	TAX	ACCOUNT,	
PLEASE	PROVIDE	THE	APPROPRIATE	INFORMATION	BELOW.

DATE	OF	CHANGE	   c	 DISCONTINUED	     c	 CHANGE	IN		 c	        OTHER
	 	               	  NO	NEW	OWNER	     	  OWNERSHIP	  	         PLEASE	EXPLAIN	BELOW)
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NEW	OWNER’S	NAME		   	   ____________________________________________________________________

NEW	OWNER’S	ADDRESS	 	   ____________________________________________________________________

	 	               	  	   ____________________________________________________________________

DID	YOU	CONTINUE	TO	OPERATE	ANY	OTHER	BUSINESS	WITH	EMPLOYEES	IN	ARKANSAS	ON	THE	DATE	
SHOWN	ABOVE?	    c	 YES	 c	 NO	 	 	 IF	YES,	GIVE	THE	NAME	AND	ADDRESS	OF	THE	BUSINESS.

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SIGNATURE	___________________________	 DATE	__________________	 TELEPHONE	________________

IF	ANY	CHANGES	ARE	NECESSARY,	PLEASE	RETURN	THIS	NOTICE	WITH	YOUR	COMPLETED	
CONTRIBUTION	AND	WAGE	REPORT.	FOR	INFORMATION	CALL	501/682-3798

  COMMENTS:
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DO NOT ALTER YOUR PRE-PRINTED EMPLOYER CONTRIBUTION AND WAGE REPORT
                                                                            DWS-ARK-209STA
                                                                            (REV.	06-06)