Employer Account Change Form
UCS-3
R. 08/07
Current legal entity name:
Unemployment tax
account number:
–
SECTION 1: CONTACT INFORMATION
Trade name (business, trade, or fictitious [d/b/a] name):
Mailing address (street address, city state, ZIP):
Business location (street address, city, state, ZIP):
Contact (name):
Phone:
–
–
E-mail address:
Fax:
–
–
Change federal employer identification number to:
–
(attach supporting IRS documentation)
SECTION 2: CORPORATION
❏ Amendment to corporate charter (attach Articles of Amendment)
❏ Officer change only
❏ Stock sale only
❏ Corporate name change to:
❏ Change in business activity (Indicate new business activity):
SECTION 3: CEASED OPERATIONS
Date of last payroll in Florida :
–
–
SECTION 4: CHANGE IN BUSINESS STRUCTURE/LEGAL ENTITY STATUS (eg: sole proprietor to corporation, corporation to LLC, etc.)
New legal entity name:
(Check one) ❏ Sole proprietor
❏ Partnership ❏ Corporation
Date change occurred:
–
–
If LLC, classification for federal income tax purposes:
(Check one) ❏ Sole proprietor
❏ Partnership ❏ Corporation
SECTION 5: SOLD BUSINESS
Date business sold:
–
–
❏ All ❏ Portion
Was there any common ownership, management or control between
the two entities at the time the sale/change occurred? ❏ �es ❏ No
Sold business to (legal entity name of new owner):
Address (street address, city, state, ZIP):
Phone:
–
–
SECTION 6: LEASING EMPLOYEES
Leasing employees: ❏ �es ❏ No
Are all employees (including corporate officers) leased? ❏ �es ❏ No
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Leasing company's DBPR license number:
–
Date leasing relationship began:
–
–
SECTION 7: SIGN AND DATE
I certify that I am legally authorized to make these changes with respect to the account number shown above.
Signature:
Date:
–
–
Title:
Phone:
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–
Sign, date, and mail this E