MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS                               OFFICE USE ONLY 
                      DIVISION OF EMPLOYMENT SECURITY        Phone: 573-751-3340 
                      P.O. Box 59, Jefferson City, MO 65104-0059        Fax:  573-751-7483            A/N             
                      EMPLOYER CHANGE REQUEST                                                         LIA9            -ID            
                                                                                                                                      
CURRENT NAME/ADDRESS                                                  MY FEDERAL ID NO. HAS CHANGED OR IS INCORRECT 
Name                                                                             
Address                                                                
                                                                      Employer Account Number             
                                                                      Phone Number            
                                                                      E-mail            
              My Name or Address Has Changed 
 
I NO LONGER HAVE EMPLOYEES BECAUSE 
Date of Change                                   Date Last Wages were Paid                                 
  Closed Business                                 Entire Business Sold                          Corporation/LLC formed/dissolved 
  Operate without employees                       Merger                                        Change in Partnership 
  Lease Employees                                 Partial Sale Only                             Stock Ownership or Officer/Member change 
  Death of Owner      Date of Death                           
  Bankruptcy                Case #                                     Court            
                      Date Filed                                        Chapter            
  Use Independent Contractors          Please attach list of contractors used including name, address, phone, SSN/FEIN. 
  Other (please explain)             
                                        
New Owner/Operator’s Name, Address, and Telephone Number 
                                                                                                                                          
Did the new owner/operator continue your business without interruption?           Yes           No 
Did the new owner/operator acquire 100% of your Missouri business activities?     Yes           No 
     If “No,” indicate the percentage of Missouri business operations acquired:              % 
Explain what portion of the business was acquired             
Is there common ownership, management or control with the previous owner/operator?           Yes      No 
New Owners, Partners, Officers  
 Name                                                                   Name             
 Address                                                                Address             
 City, State, ZIP                                                       City, State, ZIP             
Previous Owners, Partners, Officers 
 Name                                                                   Name             
 Address                                                                Address             
 City, State, ZIP                                                       City, State, ZIP             
 
Signature of Person Completing this Form                                                                  Date 
                                                                                                                     
Print Name and Title                                                                                      Telephone Number 
 
                             Missouri Division of Employment Security is an equal opportunity employer/program. 
                             Auxiliary aids and services are available upon request to individuals with disabilities. 
                                                                                                                         MODES-9 (08-13)  AI 
                                                                                                                                         Cont.