JOB SERVICE NORTH DAKOTA 
                     BUSINESS TERMINATION/INACTIVATION                                                        UI/TAX & FIELD SERVICES 
                     NOTICE                                                                      PO BOX 5507, Bismarck ND 58506-5507 
                                                                                                                          701-328-2814
                     JOB SERVICE NORTH DAKOTA                                                                                  FAX 701-328-1882 
                     UNEMPLOYMENT INSURANCE                                                                   TTY RELAY ND 800-366-6888 
                     SFN 51704 (R. 3-19) 

Account Number: 

Business Name: 

 Terminated Business  Sold Business            Changed Ownership                                               Inactivate 
Reason: 

On (date): 

Date last wages were/will be paid: 

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.