"Employer Change Request" - Mississippi

Employer Change Request is a legal document that was released by the Mississippi Department of Employment Security - a government authority operating within Mississippi.

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Mississippi Department of Employment Security
P.O. Box 22781
Jackson, MS 39225-2781
EMPLOYER’S QUARTERLY WAGE AND CONTRIBUTIONS REPORT
EMPLOYER CHANGE REQUEST
Complete this form ONLY if your name, address, federal ID No., ownership or business has changed.
Please enter the following REQUIRED information before filling out this form.
Name:__________________________________________
E-mail address:___________________________________
If there have been no changes, DO NOT submit this form for processing.
Reporting Employer’s MDES Account No.
Reporting Employer’s Name and Address (as it appears
_____________________________________ on your last Quarterly Contribution Report)
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
1. If your name or address is incorrect or has
3. If you have discontinued your business, ceased having
changed from that shown on your last quarterly employment, or had a change in ownership, please
contribution report, enter corrections or
indicate changes below:
change below:
______________________________________
Date
______________________________________ No more employees after:
_______________
______________________________________ Business discontinued:
_______________
______________________________________ Entire business sold:
_______________
______________________________________ Partial sale only, not out of business:_______________
______________________________________ Corporation formed:
_______________
Merger:
_______________
2. If your Federal Identification Number is
Partners added or withdrawn:
_______________
different from that shown on your last
Other: Explain-________________________________
Quarterly Summary Report, enter your
_____________________________________________
correct number here:
_____________________________________________
______________________________________ _____________________________________________
New owner’s name, address, and telephone number:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
I certify that this information is true and correct to the best of my knowledge and belief.
__________________________________________
_________________________________
Authorized Representative (please type)
Date
__________________________________________
__________________________________
Title
Telephone Number (including area code)
Mississippi Department of Employment Security
P.O. Box 22781
Jackson, MS 39225-2781
EMPLOYER’S QUARTERLY WAGE AND CONTRIBUTIONS REPORT
EMPLOYER CHANGE REQUEST
Complete this form ONLY if your name, address, federal ID No., ownership or business has changed.
Please enter the following REQUIRED information before filling out this form.
Name:__________________________________________
E-mail address:___________________________________
If there have been no changes, DO NOT submit this form for processing.
Reporting Employer’s MDES Account No.
Reporting Employer’s Name and Address (as it appears
_____________________________________ on your last Quarterly Contribution Report)
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
1. If your name or address is incorrect or has
3. If you have discontinued your business, ceased having
changed from that shown on your last quarterly employment, or had a change in ownership, please
contribution report, enter corrections or
indicate changes below:
change below:
______________________________________
Date
______________________________________ No more employees after:
_______________
______________________________________ Business discontinued:
_______________
______________________________________ Entire business sold:
_______________
______________________________________ Partial sale only, not out of business:_______________
______________________________________ Corporation formed:
_______________
Merger:
_______________
2. If your Federal Identification Number is
Partners added or withdrawn:
_______________
different from that shown on your last
Other: Explain-________________________________
Quarterly Summary Report, enter your
_____________________________________________
correct number here:
_____________________________________________
______________________________________ _____________________________________________
New owner’s name, address, and telephone number:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
I certify that this information is true and correct to the best of my knowledge and belief.
__________________________________________
_________________________________
Authorized Representative (please type)
Date
__________________________________________
__________________________________
Title
Telephone Number (including area code)