Form De 24 - Change Of Employer Account Information
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1CHANGE OF EMPLOYER ACCOUNT INFORMATION
ENTER YOUR E.D.D.
-
-
ACCOUNT NUMBER:
Mail to:
Employment Development Department
Corporation/
Account Services Group MIC 28
Owner’s Name:
PO Box 826880
Sacramento CA 94280-0001
Business
(DBA) Name:
PLEASE INDICATE CHANGES/CORRECTIONS THAT APPLY TO YOUR BUSINESS (A-1 BELOW):
A. Address Change / Correction:
Date of Change:
(Enter address information in box 1)
/
/
1.
NUMBER AND STREET
CITY, STATE, AND ZIP CODE
PHONE NUMBER
(
)
B. Business Name (DBA) Change:
Date Of Change:
/
/
C. Corporation Name Change:
Date Of Change:
/
/
D. Personal Name Change (i.e.; marriage):
Date Of Change:
/
/
E. Discontinued Paying Wages. Date last wage payment was made:
/
/
F. If your payroll is now being reported by a Professional Employer Organization (PEO), please provide PEO
information:
PEO Name:
PEO Address:
G. Out Of Business (Without A Successor). Date of Change:
(Provide forwarding address in box 1)
/
/
REMINDER: Please submit your final Tax Deposit Coupon (DE 88) with payment, Quarterly Wage and Withholding Report
(DE 6), and Annual Reconciliation Statement (DE 7), when discontinuing paying wages or upon going out of business.
H. Change of Ownership – Date Of Change:
(Mark appropriate box below, and complete box 2 if
/
/
required):
Partial Sale, Not Out-Of-Business
Entire Business Sold (Enter successor[s] information in box 2)
Corporation Formed
Partnership To Sole (Enter sole proprietor’s information in box 2)
Corporation Dissolved
Other (Explain):
2.
OWNER’S NAME(S) FOLLOWING
BUSINESS NAME (DBA) /
MAILING
TITLE
CHANGE OF OWNERSHIP
CORPORATION NAME
ADDRESS
SOS Corporation,
New FEIN (Tax ID#):
-
OLD FEIN (Tax ID#):
-
LLC, LLP, or LP
Explain reason for new Tax ID:
Identification #:
I.
Change in Partner(s), Officer(s), Member(s), Manager(s), etc. (Mark appropriate box to Add [A], Withdraw [W]
or if Not Applicable [N/A] in box 3, and enter the new information as required):
3.
DATE OF
INDIVIDUAL(S) TO BE ADDED/
DRIVER’S
TITLE
SOCIAL SECURITY #
CHANGE
WITHDRAWN/NOT APPLICABLE
LICENSE #
A
W N/A
/
/
/
/
/
/
Note: If business corporation/owner is represented by an authorized agent for employment tax purposes, the agent may sign
below. A signed and properly executed power of attorney must be attached or on file. THE SIGNATURE OF ANY OTHER
PERSON/THIRD PARTY WILL NOT BE ACCEPTED.
“I certify under penalty of perjury that the above information is true and correct, and that these actions are not being taken to receive a more
favorable Unemployment Insurance Rate. I further certify that I have the authority to sign on behalf of the above business.”
(
)
/
/
Signature
Phone Number
Date
Print Name
Title (Officer, Owner, Member, GP, or Authorized Agent)
DE 24 Rev. 4 (6-05) (INTERNET)
Page 1 of 1
CU
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