BUSINESS TERMINATION/INACTIVATION NOTICE                                                 JOB SERVICE NORTH DAKOTA 
                                                                                                              UI/TAX & FIELD SERVICES 
                     JSND/UNEMPLOYMENT INSURANCE                                                 PO BOX 5507, Bismarck ND 58506-5507 
                     SFN 51704 (R. 12-22)                                                                                 701-328-2814
                                                                                                                          FAX 701-328-1882 
                                                                                                              TTY RELAY ND 800-366-6888 

Account Number: 

Business Name: 

 Terminated Business              Sold Business     Changed Ownership                                          Inactivate 
Reason: 

On (date): 

Date last wages were/will be paid in North Dakota: 

New Owner’s Name: 

Address: 

City:                                              State:                                                     ZIP Code: 

Telephone Number: 

Your Future Address: 

City:                                              State:                                                     ZIP Code: 

Telephone Number: 

Signature:                                                                                                    Phone: 

Title:                                                                                                        Date: 

                     Job Service North Dakota is an equal opportunity employer/program provider. 
                     Auxiliary aids and services are available upon request to individuals with disabilities.