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MCL 421.1 et seq. |
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TE OF MICHIGAN |
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GRETCHEN WHITMER |
DEPARTMENT OF LABOR AND ECONOMIC OPPORTUNITY |
SUSAN R. CORBIN |
GOVERNOR |
UNEMPLOYMENT INSURANCE AGENCY |
ACTING DIRECTOR |
EMPLOYER REQUEST FOR NAME/ADDRESS CHANGE
ONLY SUBMIT THIS FORM IF THERE IS A NAME OR ADDRESS CHANGE

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Former |
Employer Name: _________________________________________________________ |
Employer Account No.:_______________________ |
Federal Employer ID No.: ______________________________ |
New Employer Name: ____________________________________________________ |
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DBA: __________________________________________________________________ |
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Email Address: ___________________________________________________________ |
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The Power of Attorney on file is responsible for all mailing to a representative. The address of a representative should not be on this form. |
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Physical Michigan Location of the Business |
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Mailing Address |
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(No Post Office Boxes) |
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Street Address 1: |
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Street Address 2: |
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Street Address 2: |
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Employer's Telephone Number: |
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Corporate Office |
Owner |
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Changing Account Information: If you have discontinued or ceased business activity, discontinued employment, sold or transferred ownership of all or part of your business, formed a new partnership or corporation, merged, or changed your status as a sole proprietorship or corporation, you must file Form UIA 1772, Notice of Change. You may submit Form UIA 1772 through your Michigan Web Account Manager (MiWAM) or you may download and print the form. Mail the completed form with your changes to: Unemployment Insurance Agency, P.O. Box 8086, Royal Oak, MI 48086, or fax it to 1-517-636-0014.
You can also access your MiWAM account to change your address and other account information. Other changes, including FEIN changes or bankruptcy filing, etc., must be submitted in writing with supporting documentation.
You MUST sign and date this form, giving your title and telephone number, before changes will be accepted.
Preparer: ___________________________________ Title:_______________________________________
Date: __________________ Preparer Telephone No.: _______________________
Direct any questions to the Office of Employer Ombudsman (OEO) through your MiWAM account at www.michigan.gov/uia. TTY service is available at 1-866-366-0004.
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*010252002* |
UIA is an equal opportunity employer/program. |
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