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State of Michigan |
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Department of Labor & Economic Growth |
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UIA 1025 |
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UNEMPLOYMENT INSURANCE AGENCY |
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Authorized by |
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Tax Office |
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(Rev. 03-04) |
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MCL 421.1, et seq. |
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P.O Box 8068 • Royal Oak, Michigan 48068-8068 |
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www.michigan.gov/uia |
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Employer Request For Address/Name Change |
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Current Employer Name: _________________________________________________________________________________ |
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UIA Employer Account No.: _________________________ |
Federal Employer ID No. (FEIN): ________________________ |
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New Employer Name: ___________________________________________________________________________________ |
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DBA: _________________________________________________________________________________________________ |
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E-Mail Address: ________________________________________________________________________________________ |
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PLEASE DO NOT SUBMIT THIS FORM UNLESS THERE HAS BEEN A CHANGE IN NAME OR ADDRESS. |
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Physical Location of the Business |
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Mailing Address |
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No Post Office boxes, please. |
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(Include both addresses, even if only one has changed.) |
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Street: |
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Street: |
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City: |
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City: |
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State: |
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Zip Code: |
– |
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State: |
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Zip Code: |
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– |
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E-Mail Address: |
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E-Mail Address: |
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Mailing Address is: |
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Employer's Telephone Number: ( |
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Accountant/Employer Rep* |
Corporate Office |
Owner |
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*To request a change of mailing address to an employer representative (CPA, Service Bureau, Attorney, etc.) YOU MUST FILE A POWER OF ATTORNEY AUTHORIZATION FORM.
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 a Report of Discontinuance or Disposition of Business, Form UIA 1772.
To request Form UIA 1772, check here
or call the number(s) listed below.
THE CORRECTION OF A PREVIOUSLY FILED REPORT (UIA 1020) MUST BE MADE ON AN Amended Quarterly Tax Report, Form UIA 1021. 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.: ( ________ ) _________________________
If you need assistance, telephone 1-800-638-3994, outside Michigan 1-313-456-2180.
Mail this form with your changes to the above address, or fax to (313) 456-2130. If known, indicate your Tax Team ____.
FORMS MAY BE FAXED TO YOU 24 HOURS A DAY BY CALLING: 1-800-638-3994 FORMS CAN ALSO BE OBTAINED ON
OUR WEBSITE: www.michigan.gov/uia.