Commonwealth of Massachusetts Division of Unemployment Assistance Massachusetts Department of Workforce Development Employer Liability 19 Staniford Street, 5th floor Boston, MA 02114 Division of Unemployment Assistance Application to Suspend the Filing of Employer’s Quarterly Contribution Reports DUA Employer Number: Date: Name: (617) 626-5050 Address: Fax #: (617)727-8221 To assist employers in filing quarterly contribution reports, DUA sends pre-printed contribution reports to all employers on our active file. If you no longer have employees in covered employment in Massachusetts, complete this form in all details and return to the above address within ten days. If your application is not approved, you will be notified. If your application is approved, DUA will stop sending quarterly contribution reports, but you will continue to be subject to the Massachusetts Unemployment Insurance Law and are required to notify this agency immediately whenever you employ one or more individuals either full or part time. Office Use Only ______________ Determined By A/O Reason #_____________ A Enter the last day on which any individual in employment subject to the Massachusetts Unemployment Insur ance Law (MGL C. 151A) was paid wages by you, whether employed full or part time. (Officers of corporations are considered employees if compensated.)_________________________________________________ month/day/year B This business was sold or transferred: in whole in part on:_________________________to: month/day/year Name:_____________________________DUA Employer #_________________________FEIN:_________________ Address:________________________________________________________________________________________ PLEASE NOTE: THE SUCCESSOR EMPLOYER MUST FILE AN EMPLOYER’S STATUS REPORT (DUA Form 1110) WITHIN 120 DAYS OF TAKING OVER A BUSINESS. TO OBTAIN A FORM, PLEASE CALL (617) 626-5050. This form can also be downloaded at www.mass.gov/dwd C Reason for filing this application: (4) Operating without employees (7) Bankruptcies, Assignments D Change of ownership (3) Business permanently discontinued (5) No employees in covered employment (6) No employees in Massachusetts (10) Other:_________________________ (11) Do you expect to pay wages in the future? Yes No E Payroll records will be maintained by:_____________________________, at the following address: ______________________________________________________________________________________________ I hereby certify that the statements made herein are true and correct to the best of my knowledge and belief. THIS STATEMENT IS MADE UNDER THE PENALTIES OF PERJURY. Name of Employer:___________________________________________ By: _____________________________________ Telephone Number______________________________________ Date: ________________________________________ Form L -0740 Rev. 08-06 American LegalNet, Inc. www.FormsWorkflow.com