Form Ldol Es4 A - Employer'S Report Of Change
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1LOUISIANA DEPARTMENT OF LABOR
EMPLOYER'S
OFFICE OF REGULATORY SERVICES
REPORT OF CHANGE
P. O. BOX 94186
BATON ROUGE, LA 70804-9186
Complete form online, print, then fax to 225-342-1943.
1.
2.
STATE ID NUMBER:
HAS BUSINESS CEASED OPERATION?
YES
NO
2A.
IF YES, COMPLETE SECTIONS B, C, AND/OR D
AS APPLICABLE.
PART A.
PART B.
CURRENT ACCOUNT INFORMATION
CHANGES TO ACCOUNT INFORMATION
EMPLOYER NAME, DBA NAME & MAILING ADDRESS:
IF YOU HAVE A NAME OR FEIN CHANGE, ALSO ANSWER PART C
3A.
3B.
4A.
PHYSICAL LOCATION OF BUSINESS IN LOUISIANA:
4B. PHYSICAL LOCATION OF BUSINESS IN LOUISIANA:
5A.
5B.
BUSINESS PHONE NUMBER:
EXT:
EXT:
6A.
6B.
BUSINESS FAX NUMBER:
7A.
7B.
E-MAIL ADDRESS:
8A.
8B.
LOUISIANA REVENUE NUMBER:
9A.
9B.
FEDERAL ID NUMBER (FEIN):
(ALSO ANSWER PART C)
IF FEIN CHANGE IS FOR NEW OWNER OR DUE TO CONTRACT WITH PEO/LEASING ORGANIZATION, ANSWER PART C.
C.
CHANGES IN OWNERSHIP OR OPERATIONS:
YES NO
1. HAS THE LEGAL STATUS OF YOUR BUSINESS CHANGED?
(Examples of Legal Status Change: FEIN number change, individual to corporation, corporation to LLC, etc.)
2. HAS THE BUSINESS NAMED IN # 3A PURCHASED ANOTHER BUSINESS?
3. HAS THE BUSINESS NAMED IN #3A BEEN SOLD?
4. DO YOU HAVE A CONTRACT WITH A PEO/LEASING ORGANIZATION?
IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS IN PART C, PROCEED TO PART D
D.
PROVIDE THE FOLLOWING INFORMATION:
1. EFFECTIVE DATE OF CHANGE:
2. DATE LAST WAGES PAID FOR ACCOUNT IN # 3A:
ENTER INFORMATION ABOUT BUSINESS PURCHASED, NEW OWNER OR PEO:
3. NAME:
4. TRADE NAME / DBA NAME:
5. STREET ADDRESS:
6. CITY, STATE & ZIP CODE:
PHONE NUMBER:
7. CONTACT PERSON:
EXT:
E.
NAME CHANGES FOR CORPORATE ENTITIES CANNOT BE UPDATED UNTIL YOU PROVIDE CERTIFICATION OF
THE CHANGE FROM THE OFFICE OF THE SECRETARY OF STATE.
ENTER THE NAME & PHONE NUMBER OF THE PERSON TO CONTACT REGARDING INFORMATION FOR THIS ACCOUNT.
SIGNATURE:
PRINTED NAME:
TITLE:
PHONE:
EXT:
DATE:
NOTICE: YOU CAN NOW DIRECTLY POST YOUR JOB OPENINGS ON OUR
WEB SITE
LDOL ES4 A REV. 04/2007
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