Mail To:                                                                                                                                   This form can be completed online at 
 Cashier - Texas Workforce Commission                        Amended Status Report                                                          www.texasworkforce.org  
P.O. Box 149037 
 Austin, TX 78714-9037                             
 512.463.2731                                          This report is to update your account with TWC                                                                                                        
 
                                                                    *Indicates required information. 
 
                                                                            Identification Section 
 *1. Account Number assigned by TWC                                                   *5. Federal Employer ID Number  
                                                                                                     
 *2. Name                                                                             *6. Area Code/Phone Number  
                                                                                                     
 *3. Mailing address                                                                  *7. Address where payroll records are kept  
                                                                                                     
 *4. City, State, Zip                                                                 *8. City, State, Zip where payroll records are kept 
                                                                                                     
 *9. Owners or Officers 
                       Name                            Soc. Sec. No.            Title                             Residence Address, City, State 
                                                                                                                  
 10. Business locations in Texas                                                                                                                                                                                              
                       Trade Name                                                    Street Address, City                                                                                                   Kind of Business No. Employees 
                                                                                                                                                                                                                                        
                                                                                Acquisition Section 
 11. If you acquired the business in Texas from a previous owner, you must complete Items 11-13. 
                                If a partial acquisition, the predecessor/successor may jointly submit an application for partial transfer of experience.                                                                                
                     a. Acquisition Date :                           Month                           Day                        Year                                                                                                        
                     b. Previous Owner’s TWC Account Number (if known):                                                                                                                                                                  
                     c. Previous Owner’s Name:                                                                                                                                                                                           
                     d. Previous Owner’s Address:                                                                                                                                                                                        
                     e. City, State, Zip:                                                                                                                                                                                                
                     f. Portion of business acquired:  (check one):    All                              Part (specify which part of business was purchased)              
 12.   On the date of the acquisition, was the previous owner(s), or any partner(s), officer(s), shareholder(s), other owner(s) or a person elated by blood or marriage to any 
  of these individuals, holding a legal or equitable interest in the predecessor business, also an owner, partner, officer, shareholder, or other owner of a legal or equitable 
  interest in the successor business?          Yes       No  
  
 If “Yes”, check all that apply: 
                       Same owner, officer, partner, or shareholder    Same parent company                          Sole proprietor incorporating 
                    
                       Other if other, please describe______________________________________________________________________________________ 
     
  If “No”, on the date of the acquisition, did the previous owner(s), partner(s), officer(s), shareholder(s), other owner(s) or a person elated by blood or marriage to any of 
     these individuals, holding a legal or equitable interest in the predecessor business, hold an option to purchase such an interest in the successor business?  
                       Yes                No 
 13. After the acquisition, did the predecessor continue to:   
     •             Own or manage the organization that conducts the organization, trade or business? 
     •             Own or manage the assets necessary to conduct the organization, trade or business? 
     •             Control through security or lease arrangement, the assets necessary to conduct the organization, trade or business?  
     •             Direct the internal affairs or conduct of the organization, trade or business?  
                         Yes                   No 
   If “Yes" to any of above, describe:                                                                                                                                                                      
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                                                                                        Reopen Section 
 14. If you are filing this report to reactivate your inactive account, complete this section. 
  
                         The date you resumed employing individuals in Texas:                              Month                      Day                 Year      
                         The date you resumed paying wages in Texas:                                             Month                      Day                 Year      
            
                                                                                        Suspend Section 
     If you sold a business in Texas you must complete Items 15 through 17 
 15. If you are filing this report to inactivate your account, complete this section.                                                                                                                                               
                                                                                                                                                                                                                                    
                         The last day on which individuals performed services in Texas:               Month                   Day                  Year       
                         The date on which final wages were paid:                                                    Month                   Day                  Year                                                              
Employment in Texas was discontinued because: (Check one):                     Business discontinued entirely without a successor. 
                                                                               Business continued without employment. 
                                                                               Business, trade or organization was acquired by a successor.  
                                                            If a partial acquisition, the predecessor/successor may jointly submit an application for partial transfer of experience. 
                           Successor’s TWC Account Number (if known):                                                                                                                                                                
                                                                                                                                                                                                                                    
                                                            Successor’s Name:                                                                                                          
                                                        Successor’s Address:                                                                                                                                                        
                                                            City, State, Zip:                                                                                                                                                       
 
 Successor Acquired:                  All the Texas business or assets. 
     (Check one):                     Part of the Texas business or assets.    Part Acquired (specify):                                                                                                                             
 16.   On the date of the acquisition, was the previous owner(s), or any partner(s), officer(s), shareholder(s), other owner(s) or a person related by blood or marriage to 
   any of these individuals, holding a legal or equitable interest in the predecessor business, also an owner, partner, officer, shareholder, or other owner of a legal or 
   equitable interest in the successor business?               Yes                 No 
 If “Yes”, check all that apply: 
                              Same owner, officer, partner or shareholder                                          Sole proprietor incorporating 
                              Same parent company                                                                  Other  (Described below) 
                                                                                                     ________________________________________________________ 
        
  If “No”, on the date of the acquisition, did the previous owner(s), partner(s), officer(s), shareholder(s), other owner(s) or a person related by blood or marriage to any of 
     these individuals, holding a legal or equitable interest in the predecessor business, hold an option to purchase such an interest in the successor business?                                  
                           Yes                       No 

 17.   After the acquisition, did the predecessor continue to: 
     •      Own or manage the organization that conducts the organization, trade of business? 
     •      Own or manage the assets necessary to conduct the organization, trade or business? 
     •      Control through security or lease arrangement the assets necessary to conduct the organization, trade or business? 
     •      Direct the internal affairs or conduct of the organization, trade or business? 
 
                            Yes                         No 
     If “Yes” to any of above, describe:   
                                                                                                                                                                                       
                                                                                        Signature Section 
 *18. I hereby certify that the preceding information is true and correct, and that I am authorized to execute this Amended Status Report on behalf of the employing unit  
     named herein. (This report must be signed by the owner, officer, partner OR individual with a valid Written Authorization on file with the Texas Workforce 
     Commission.) 
  Date of signature:                                                                                                                                                            
                                                                                                                                                                                
     Month     ___  Day     ___   Year     ___                 Sign here   ________________________________________                                                                               Title           _______________ 
   
  Driver's license number           _____________________                 State     _____________________                E-mail address           _________________ 

   Individuals may receive, review, and correct information that TWC collectsthabout the individual by emailing toopen.records@twc.state.tx.us  or writing to TWC Open 
                                                               Records, 101 East 15  St., Rm. 266, Austin, TX 78778-0001. 
                                                                                                    
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