VERMONT DEPARTMENT OF LABOR                                       Telephone: (802) 828-4344                                 VERMONT EMPLOYER NO.
ATTN: EMPLOYER SERVICES, P.O. Box 488                             Fax: (802) 828-4248
Montpelier, Vermont 05601-0488
NOTICE OF CHANGE       C-36 (12/10)

Complete all items applicable to your organization, trade, business or employment in Vermont.
Nature of Change: Change of Address/Trade Name > Complete Part A, D & E               Ceased Employment > Complete Part B, D & E
 Sale/Lease/Reorganization of Business > Complete Part C, D, & E
  CHANGE OF ADDRESS/TRADING AS: Corrections to Name and/or Address of record. (NO CHANGE IN OWNERSHIP OR BUSINESS TYPE)
  Name: ____________________________________________________   Contact: ____________________________________________________
A Trading As:  ________________________________________________    Telephone: _________________________________________________
  Address:  __________________________________________________    Fax & Email: ________________________________________________
  CEASED EMPLOYMENT
  Date Employment Ended: ____________________         Final Pay Date: ____________________
  No Longer have Vermont Employees    Explain: __________________________________________________________________
  Discontinued operations in Vermont  Explain: __________________________________________________________________
B Out of Business - Reason:            Ceased Business / Closed               Filed for Bankruptcy               Foreclosure
  Location of all employment records:
  Address: ___________________________________________________________________________________________________________
  Contact: ________________________________         Telephone:  _________________________       Fax: _____________________________
  Email Address: ____________________________________
  If your business is a Corporation, are your officers receiving any wages or draws after the effective date?           Yes                     No

  SALE / LEASE / REORGANIZATION OF BUSINESS    (PLEASE PROVIDE THE FOLLOWING INFORMATION)
  1.  Date of Change    _____________________     2.  Date Final Wages Paid    _____________________
  3.  Nature of change:
  ALL   of Vermont Business Sold                     PART of Vermont Business Sold
  ALL   of Vermont Business Leased                   PART of Vermont Business Leased
  Reorganization of Business
  4. Did you retain title or control of any assets?            No            Yes - If "Yes"            ALL               PART (Specify percentages below)
  LAND BUILDINGS       INVENTORY     MACHINERY VEHICLES OFFICE    FURNITURE       ACCOUNTS          FRANCHISE               OTHER-SPECIFY
                                                        EQUIPMENT & FIXTURES      RECEIVABLE                                TYPE & PERCENTAGE
                                                                                                                            ON ATTACHED SHEET.
C
  5.  Other Assets retained: _________________________________________________________________ Percentage Retained: _______%
  6.  Enter the complete name, trading as, address and telephone number of the new owners/operators of the business:
       Legal Business Name  ___________________________________________________________________________________________
       Trading As  ____________________________________________________________________________________________________
       Mailing Address ________________________________________________________________________________________________
       City, State, Zip  _________________________________________________________________________________________________
       Contact: _______________________  Telephone Number: _____________________  Email Address: ____________________________
  7. Is there any common ownership between the two businesses?          Yes          No          If Yes, attach explanation
                                     SECTION C CONTINUED ON PAGE 2

  8.  Will the new entity continue to operate this business?       Yes                  No       If No, Explain:
  __________________________________________________________________________________________________________________
  _
  __________________________________________________________________________________________________________________
  _
  9.  Will you continue to pay wages after the change to your business occurs?           Yes                No
       If "Yes", please provide reason: ______________________________________________________________________________________
  __________________________________________________________________________________________________________________
      ________________________________________________________________________________________________________________
  10.  Will you continue to operate a business under this legal entity?               Yes                No
       If "Yes", please give the name and the nature of the business retained/continued: ______________________________________________

   _________________________________________________________________________________________________________________
  11.  Will you be starting a new business under this legal entity?                 Yes                No

         If "Yes", provide the following:        Name of Business: ____________________________________________________________________
       Nature of Business:  _____________________________  Start Date: ________________  Date First Wages to be Paid: _______________
  12.  Will direction and control of the business remain the same?              Yes                 No
C
      Be advised that the sellar of a busines is required to disclose its experience rating to a potential buyer upon
      request, in accordance with §1325(b)(1).
  FOR LEASED BUSINESS ONLY
  13.  Did the title to any assets go to the lessee? Yes               No          If, "Yes", please provide information on the assets:

  __________________________________________________________________________________________________________________
  _
  __________________________________________________________________________________________________________________
  _
  __________________________________________________________________________________________________________________
  _
  14.  Please describe in detail the nature of the leased business:
  __________________________________________________________________________________________________________________
  _
  __________________________________________________________________________________________________________________
  _
  __________________________________________________________________________________________________________________
  _
  15. I understand that as the seller of a business, I am required to disclose the Unemployment Insurance tax expereince rating to
      a potential buyer upon request, in accordajnce with 1325(b).§
        I have read and understand the proceededing statement.

  16.  Please describe any other changes not specified above: __________________________________________________________________
  __________________________________________________________________________________________________________________
  _
D __________________________________________________________________________________________________________________
  _
  __________________________________________________________________________________________________________________
  _

  I CERTIFY THE ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

  Contact Name: __________________________________ Telephone: ________________ Ext. _______  Fax: _________________________

E

  Signature: _______________________________________  Title: ___________________________________  Date: ____________________