Employer Change Of Address Request Form
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Employer Change Of Address Request Form. This is a Massachusetts form and can be use in Department Of Employment And Training Statewide.
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Tags: Employer Change Of Address Request Form, 0566, Massachusetts Statewide, Department Of Employment And Training
Revenue Service
Central Address Unit
Tel: (617) 626-5040
Fax: (617) 727-8221
Massachusetts Department of
Workforce
Development
Division of Unemployment Assistance
EMPLOYER CHANGE OF ADDRESS REQUEST
FOR DIVISION USE ONLY
Request by:
(D.U.A. Employee)
Complete and return this form to:
Division of Unemployment Assistance
Revenue Service
Central Address Unit - 5th Floor
19 Staniford Street
Boston, MA 02114
Phone:
Date:
L.O. - Unit:
Source of Request:
PLEASE TYPE OR PRINT CLEARLY IN INK.
Would you like to change your address online? Go to: https: // ipasssecurity.detma.org/ipass/loginnew.asp?ipc=2
This request form is to insure that all D.U.A. mailings are sent to the correct address and to simplify reporting of address
changes. (Please use this form for change of address only!)
D.U.A. EMPLOYER NUMBER: (8 Characters)
FEDERAL I.D. NUMBER: (9 Characters)
NAME OF EMPLOYING UNIT: (Individual, Partner, Corporation)
TRADE NAME:
TELEPHONE:
LEGAL ADDRESS: (NOT a P.O. Box) (Agent address is not permitted.)
No. Street (25*)
City/Town (13*)
(
)
State (2*)
ZIP (5*)
State (2*)
ZIP (5*)
LOCATION OF PAYROLL RECORDS: (NOT a P.O. Box)
No. Street (25*)
City/Town (13*)
MAILING ADDRESS: Employer's Quarterly Contribution Report (D.U.A. Form 0001) (Agent address is not permitted.)
No. Street or P.O. Box (25*)
City/Town (13*)
State (2*)
ZIP (5*)
Request for Separation and/or Wage Information (Claim) (D.U.A. Form 1062/1074) (Agent address is permitted.)
No. Street or P.O. Box (25*)
City/Town (13*)
State (2*)
ZIP (5*)
Statement of Benefit Charges or Benefits Paid/Statement of Reimbursable Benefits (D.U.A. Form 1088/1089-1) (Agent address
is permitted.)
No. Street or P.O. Box (25*)
City/Town (13*)
State (2*)
ZIP (5*)
* Indicates the maximum number of characters for computer entry.
I understand that by designating an agent or organization to receive the above forms, Request for Separation and/or Wage
Information (Claim) (1062/1074) and Statement of Benefit Charges or Benefits Paid/Statement of Reimbursable Benefits
(1088/1089-1), I am agreeing to be bound by my agent's actions or inactions regarding any action required or permitted
concerning those forms.
SIGNED BY:
TITLE:
DATE:
Commonwealth of Massachusetts
TELEPHONE:
Form 0566 Rev. 04-06
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