E M P L O Y E R ' S R E P O R T O F C H A N G E S
E m p l o y e r A c c o u n t N u m b e r : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ T e l e p h o n e N u m b e r : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Business Discontinued (no new ownership) ..........................................................
M o n t h / D a y / Y e a r
( P l e a s e n o t i f y t h e D i v i s i o n i f , o r w h e n , b u s i n e s s r e s u m e s . )
E x a c t D a t e o f L a s t P a y r o l l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
M o n t h / D a y / Y e a r
C h a n g e i n B u s i n e s s O w n e r s h i p - C o m p l e t e N E W O W N E R ( S ) s e c t i o n b e l o w .
Sale of Entire Business .............................................................................
M o n t h / D a y / Y e a r
Partial Sale (not out of business) ..............................................................
M o n t h / D a y / Y e a r
D e s c r i b e P a r t S o l d _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Change in Legal Ownership .....................................................................
( s u c h a s a d d i n g o r d r o p p i n g a p a r t n e r , i n c o r p o r a t i n g , e t c . )
M o n t h / D a y / Y e a r
N E W O W N E R ( S ) |
N e w F e d e r a l I d e n t i f i c a t i o n N u m b e r ( i f a p p l i c a b l e ) : |
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C h e c k T y p e o f O r g a n i z a t i o n: |
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S C o r p o r a t i o n |
S o l e P r o p r i e t o r |
L i m i t e d L i a b i l i t y P a r t n e r s h i p |
P u b l i c l y T r a d e d C o r p o r a t i o n |
A s s o c i a t i o n |
L i m i t e d L i a b i l i t y C o m p a n y |
P r i v a t e l y H e l d C o r p o r a t i o n |
P a r t n e r s h i p |
O t h e r |
N a m e a n d a d d r e s s o f n e w o w n e r ( s ) , p a r t n e r ( s ) , c o r p o r a t e o f f i c e r ( s ) , m e m b e r ( s ) , e t c . _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
R e m a r k s _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
New Business Units Added to Present Ownership .................................................
M o n t h / D a y / Y e a r
T r a d e N a m e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
L o c a t i o n _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
N a t u r e o f O p e r a t i o n _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
P r e v i o u s O w n e r ( s ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
N U C S - 4 0 7 2 ( R e v . 9 - 0 2 )
STATE OF NEVADA
DEPARTMENT OF EMPLOYMENT, TRAINING AND REHABILITATION
EMPLOYMENT SECURITY DIVISION
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Carson City, Nevada 89713-0030
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