Massachusetts Department of Workforce Development Division of Unemployment Assistance EMPLOYER DATA CHANGE FORM Do not mail this form with Form 1 Mail form(s) to: Division of Unemployment Assistance Revenue Service, Employer Liability Status Department - 5th Floor 19 Staniford St., Boston, MA 02114-2589 USE THIS FORM ONLY: • to add your Federal IRS number if it is not pre-printed on the Form 1. (Enter only in "old number" block in Item A.) • to change Federal IRS identification number. A new Employer Status Report must be filed with this form.k • to change mailing address • to report ownership changes or changes in organization type. A new Employer Status Report must be filed with this form.k • if your business has been discontinued or you are operating without employees. PLEASE COMPLETE THIS SECTION D.U.A. Employer Number: Address: Employer Name: A. CHANGE FEDERAL IRS NUMBER BELOW. OLD NUMBER NEW NUMBER 4 (If you are changing your Federal IRS number, a new Employer Status Report must be filed with this form.)k B. C. Would you like to change your address online? Go to: https://ipasssecurity.detma.org/ipass/loginnew.asp?ipc=2 Change the address of these forms to this new address. CHANGE OF ADDRESS. Check all that you wish to change: Street: n Employer's Quarterly Contribution Report (Form 1) / (Form 1700). Do not use agent's address. City: n Statement of Benefit Charges (Form 1088) Statement of State:                             Zip Code: Reimbursable Benefits (Form 1089-1). Agent's address may I understand that by designating an agent to receive Request for Separa be used. tion and/or Wage Information (Claim), Forms 1062/1074, and Statement n Request for Separation and/or Wage Information (Claim) of Benefit Charges (Form 1088), or Statement of Reimbursable Benefits (Form 1062/1074). Agent's address may be used. (Form 1089-1), I am agreeing to be bound by my agent's actions or inacn Legal address. Do not use agent's address. tions regarding any action required or permitted concerning those forms. CHANGE NAME, OWNERSHIP AND/OR STATUS. (For Assistance Call (617) 626-5050.) Name Change Enter New Legal Name: (if corporation, LLC, LLP, LP, attach articles or certificates of amendments.) Enter New DBA Name: If business was sold or transferred, check applicable block: n in whole n in part Ownership Change Name of New Owner: Employer No.: Address: Date Change Occurred: Has type of ownership (i.e., partnership, individual ownership, etc.) changed during the calendar quarter covered by this report? n Yes n No If "Yes", a new Employer Status Report must be filed with this form.k Status Change If you no longer have employees in Massachusetts, enter last day on which any individual (in employment subject to the Massachusetts Unemployment Insurance Law) was paid wages by you. Month                  Day               Year Also check reason below: n (3) Business permanently discontinued n (4) Operating without employees n (5) No employees in covered employment n (6) No employees in Massachusetts n (7) Bankruptcies, assignments, n Change in Ownership Signature is required to initiate changes above. Phone No.: Signed: k Commonwealth of Massachusetts Form 1897 Rev. 12-08 Date: Go to www.mass.gov/eolwd and download Form 1110A Employer Status Report American LegalNet, Inc. www.FormsWorkflow.com