Mail To: 
 Cashier - Texas Workforce Commission                      Amended Status Report 
 P.O. Box 149037                                  This report should be used to update your account with TWC 
Austin, TX 78714-9037 
 512.463.2731                                    Please complete Items 1 through 8, any other item that needs to 
 www.texasworkforce.org                           be updated, and sign the report in Item 20 on the back. 
                                                                                                                                                   TWC Use Only 
                                                                                                                                               County Code          Tax Area 

                                                                            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 of Records/Payroll  
                                                                                                         
   4. City, State, Zip                                                                    8. City, State, Zip  
                                                                                                         
   9. Owners’ or Officers’ Name                            Soc. Sec. No.            Title                                  Residence Address, City, State 
                                                                                                                 
   10. Business location(s) 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 11-14. 
                                                                                                                                                   Mo.         Day  Yr.         
                                                                                                                                                                                
                                                                                                                               Acquisition Date :                        
                  Previous Owner’s TWC Account Number (if known):                                                                                                               
                                                 Previous Owner’s Name:                                                                                                         
                                                 Previous Owner’s Address:                                                                                                      
                                                           City, State, Zip:                                                                                                    
Portion of business acquired:                     All 
    (check one):                                  Part (specify)                                                                                                                
   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        Yes         No 
   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? 
   If “yes”, check all that apply:                                                                                 
              Same owner, officer, partner, or shareholder            Same parent company If other, describe:                
              Sole proprietor incorporating        Other                                                                     
   13.   If “No”, on the date of the acquisition, did the previous owner(s), partner(s), officer(s), shareholder(s), other       Yes               No 
   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? 
   14. After the acquisition, did the predecessor continue to:                                                                   Yes               No 
   •  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?                                         Yes               No 
   •  Control through security or lease arrangement, the assets necessary to conduct the organization, trade or business?        Yes               No 
   •  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        
   15. If you are filing this report to reactivate your inactive account, complete this section. 
                                                                                                                                                    Mo.     Day     Yr.    
                                                                                          The date you resumed employing individuals in Texas:                             
                                                                                                 The date you resumed paying wages in Texas:                               
                                                                                                      
                                                                                Suspend Section 
   16. If you are filing this report to inactivate your account, complete this section. 
                                                                                                                                                    Mo.     Day     Yr.    
                                                                              The last day on which individuals performed services in Texas:                               
                                                                                                   The date on which final wages were paid:                                
   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 you sold a business in Texas you must complete Items 16 through 19. 
                                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):                                                                     
   17.   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) 
                                                                                                                                                                     
   18.   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     YES       NO 
   to purchase such an interest in the successor business? 
   19.   After the acquisition, did the predecessor continue to:                                                                                 
   •   Own or manage the organization that conducts the organization, trade of business?                                                           YES           NO 
   •   Own or manage the assets necessary to conduct the organization, trade or business?                                                          YES           NO 
   •   Control through security or lease arrangement the assets necessary to conduct the organization, trade or business?                          YES           NO 
   •   Direct the internal affairs or conduct of the organization, trade or business?                                                              YES           NO 
                                                                                                                                                 
   If “Yes” to any of above, describe:     
                                                                                                                                                                          
                                                                                Signature Section     
 
   20. 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.) 

                          Mo. Day  Yr.   
Date Signed                                                                                                                                                                
                                                                                Signature                                                           Title 
                                                                                                                      
                                                                                E-mail Address 
                                            Individuals may receive, review, and correct information that TWC collects  
                                            about the individual by emailing to open.records@twc.state.tx.usth        or writing           to  
                                            TWC Open Records, 101 East 15  St., Rm. 266, Austin, TX 78778-0001.
                                                                                            
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