Mail To: Mail To:                                                                                                        This form can be completed online at 
 Tax Department - Texas Workforce Commission                                                                             www.texasworkforce.org  
 P.O. Box 149037                                                       STATUS CHANGE 
Austin, TX 78714-9037 
512.463.2699 
                                                                           FORM 
 
Assigned Account Number   
 
__________________________ 
       
Enter Corrections(if needed) 
                                                         Telephone Number           ___________________ 
 
                                                         Federal ID Number           ___________________ 
                                                                                                                                                                     
Use this form to report: changes to: ownership, name, address, account number, Federal ID number or telephone number. Please fill in your account number, enter 
your corrections and return this page with your tax report. 
 
Name:                                                                      ____________________________________________________________________ 
 
Trade Name:                                                                                                                                                         
 
Address:                                                                                                                                                            
 
Claim Notification Designated Address:                                                                                                                              
                                                                                                                                                                    
Special Address for Chargeback Summary:                                                                                                                             
 
If you have discontinued employment, complete the appropriate items below: 
 
                 Business discontinued, no successor 
            
                 Business continued without employment 
            
                 Business acquired by a successor 
 
                       Enter the date of acquisition:                                                                                                               
                        
                       Date of last employment:                                                                                                                     
                        
                       Date final wages paid:                                                                                                                       
 
If your business was acquired by a successor, complete the following. If a partial acquisition occurred, the predecessor/successor may jointly submit information 
regarding a partial transfer of experience. 
 
Successor Name:                                                                                                                                                    
 
Successor Address:                                                                                                                                                 
 
Successor Account Number:                                                                                                                                          
 
Was all or part of the business acquired?                 All    Part  
 
           Which part was acquired?                                                                                                                                
 
Signature  _______________________________________________________________________ Date _______________________________________________ 
 
   Individuals may receive and review information that TWC collects about the individual by emailing to open.records@twc.state.tx.us or writing to TWC Open 
                                                              Records, 101 E. 15th St., Rm. 266, Austin, TX  78778-0001. 
 
C3SCF (071515)