Form Ncui 101-A-I - Change In Status Report
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1Account Number
CHANGE IN STATUS REPORT
Return to: Employment Security Commission
of North Carolina
Employer Name and Address:
P.O. Box 26504
Raleigh, NC 27611-6504
Nature of Change (Please check as appropriate).
A. Sold or otherwise transferred all or part of the business to:
Employer Name_____________________________________________Date of Sale_____________________
Trade Name________________________________________________Phone__________________________
Address___________________________________________________________________________________
Was the entire business operation and all its incidents (including equipment, merchandise, raw materials) sold,
transferred, or leased to new owner?
Yes_____________No____________
B. Partnership formed or changed. Explain (including effective date):_____________________________________
__________________________________________________________________________________________
C. Incorporated business (Effective date):___________________________________________________________
D. Ceased operations in North Carolina. Date operations ceased:________________________________________
E. Operating without employees. Last date of employment:_____________________________________________
F. Changed business name to:____________________________________________________________________
(If corporation, furnish copy of corporate minutes or amended charter on file with the Secretary of State)
G. Changed business location or
Mailing Address or
Telephone Number______________________________
(Telephone No.)
New Address________________________________________________________________________________
(Street)
___________________________________________________________________________________________
(City)
(State)
(Zip Code)
H. Change in person to contact for tax matters:________________________________________________________
(Name)
________________________________________________________
(Address)
________________________________________________________
(Telephone No.)
For Agency Use Only
______________________________________________
Action taken
(Signature of person authorizing change)
Operator
Date
___________________________
(Date)
NCUI 101-A-I
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Parent category: Business