Dws-Ark-209sta - Notification Of Change In Status

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Notification Of Change In Status, DWS-ARK-209 STA
This form is mailed with your “Employer’s Quarterly Contribution and Wage Report” for your conve-
nience in reporting changes affecting your account. This form must be returned to the Status and
Rate Unit, P.O. Box 2981, Little Rock, AR 72203 within ten (10) days after any change occurs.
ARKANSAS DEPARTMENT OF WORKFORCE SERVICES
NOTIFICATION OF CHANGE IN STATUS
USE THIS FORM TO REFLECT ANY CHANGES IN YOUR ACCOUNT
DWS ID Number ___________________________
FEDERAL ID NUMBER ___________________
EMPLOYER NAME ______________________________________________________________________
IF THERE HAS BEEN AN OWNERSHIP, ADDRESS OR OTHER CHANGE MADE REGARDING TAX ACCOUNT,
PLEASE PROVIDE THE APPROPRIATE INFORMATION BELOW.
c
c
c
DATE OF CHANGE
DISCONTINUED
CHANGE IN
OTHER
NO NEW OWNER
OWNERSHIP
PLEASE EXPLAIN BELOW)
_____/_____/_____
NEW OWNER’S NAME
____________________________________________________________________
NEW OWNER’S ADDRESS
____________________________________________________________________
____________________________________________________________________
DID YOU CONTINUE TO OPERATE ANY OTHER BUSINESS WITH EMPLOYEES IN ARKANSAS ON THE DATE
c
c
SHOWN ABOVE?
YES
NO
IF YES, GIVE THE NAME AND ADDRESS OF THE BUSINESS.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
SIGNATURE ___________________________
DATE __________________
TELEPHONE ________________
IF ANY CHANGES ARE NECESSARY, PLEASE RETURN THIS NOTICE WITH YOUR COMPLETED
CONTRIBUTION AND WAGE REPORT. FOR INFORMATION CALL 501/682-3798
COMMENTS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_____________________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_____________________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
DO NOT ALTER YOUR PRE-PRINTED EMPLOYER CONTRIBUTION AND WAGE REPORT
DWS-ARK-209STA
(REV. 06-06)
53

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