MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS                                                                  LIA 9 
          DIVISION OF EMPLOYMENT SECURITY        Phone: 573-751-1995 
          P.O. Box 59, Jefferson City, MO 65104-0059        Fax:  573-751-7483               Account No. 
          EMPLOYER CHANGE REQUEST 
This form should be used when there is a change to business operations or the employer contact details. 
Provide your Account Number in the space to the right. ___________________________________ 
1.  Have you sold your Missouri business?     Yes     No 
   a. If Yes, date of change________________________
   b. Reason for Sale:
           Entire Business Sold               Merger                            Corporation/LLC formed/dissolved 
           Partial Sale Only                  Change in Partnership             Stock Ownership or Officer/Member Change 
           Other (explain) ____________________________________________________________________________________  
   c. New Owner/Operator’s Information:
      Name  ______________________________________________________________________________________________
      Address _____________________________________________________________________________________________
      Employer Account Number__________________________________   Phone Number ______________________________
      Contact Person _______________________________________________________________________________________
   d. Did the new owner/operator continue your trade and business without interruption?       Yes         No 
   e. Did the new owner/operator acquire 100% of your Missouri trade or business?     Yes     No 
      i.  If No, indicate the percentage of Missouri business acquired: ________%
      ii. Explain what portion of the business was acquired ________________________________________________________
   f. Is there common ownership, management or control with the previous owner/operator?      Yes         No 
      i.  If Yes, provide details for those owners, partners or officers that are common between both entities.
      Name___________________________________________          Name___________________________________________ 
      Address _________________________________________  Address _________________________________________ 
      City, State, ZIP ___________________________________  City, State, ZIP ___________________________________ 
      Name___________________________________________          Name___________________________________________ 
      Address _________________________________________  Address _________________________________________ 
      City, State, ZIP ___________________________________  City, State, ZIP ___________________________________ 
2. Do you have employees working in Missouri?  Yes        No 
   a. If No, provide last date of payroll______________________
   b. Reason for no employees:
           Closed Business       Operate without Employees                      Use Independent Contractors 
           Lease Employees       Death of Owner                                 Bankruptcy Case # ________________________  
                                      Date of Death_______________                   Chapter _________________________________  
           Other (explain)______________________________________                     Date Filed _______________________________  
            __________________________________________________                       Court ___________________________________  
3. Current Employer Details:
   Name __________________________________________________________________________________________________
   Phone Number____________________________________  Federal ID (FEIN) _______________________________________
   Address ________________________________________________________________________________________________
   Email __________________________________________________________________________________________________

Signature                                                                            Date 

Printed Name and Title                                                               Phone Number 

IMPORTANT: If needed, call 573-751-1995 for assistance in the translation and understanding of the information in this document. 
¡IMPORTANTE!: Si es necesario, llame al 573-751-1995 para asistencia en la traducción y entendimiento de la información en este documento. 
          Missouri Division of Employment Security is an equal opportunity employer/program. Auxiliary aids and services 
          are available upon request to individuals with disabilities.   TDD/TTY: 800-735-2966   Relay Missouri: 711 
                                                                                                               MODES-9 -I(11-19)   AI 
                                                                                                                                 UITax