RESET FORM            Authorized by
     UIA 1025                                                                      MCL 421.1 et seq.
     (Rev.02-20)
                                                                                                                                             •
                                         STATE OF MICHIGAN
     GRETCHEN WHITMER        DEPARTMENT OF LABOR AND ECONOMIC OPPORTUNITY                   SUSAN R. CORBIN 
     GOVERNOR                                        UNEMPLOYMENT INSURANCE AGENCY         ACTING DIRECTOR

                             EMPLOYER REQUEST FOR NAME/ADDRESS CHANGE
        ONLY SUBMIT THIS FORM IF THERE IS A NAME OR ADDRESS CHANGE

        Current          Former          Employer Name: _________________________________________________________

Employer Account No.:_______________________ Federal Employer ID No.: ______________________________

New Employer Name: ____________________________________________________

DBA: __________________________________________________________________

Email Address: ___________________________________________________________
The Power of Attorney on file is responsible for all mailing to a representative. The address of a representative should not be on this form.
Physical Michigan Location of the Business
                                                        Mailing Address
                  (No Post Office Boxes)
Street Address 1:                                       Street Address 1:

City                           State     Zip Code       City                       State                                                     Zip Code

Street Address 2:                                       Street Address 2:

City                           State     Zip Code       City                       State                                                     Zip Code

Employer's Telephone Number:                            Mailing Address belongs to:
                                                              Corporate Office      Owner

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 Form UIA 1772, Notice of 
Change.  You may submit Form UIA 1772 through your Michigan Web Account Manager (MiWAM) or you may 
download  and  print  the  form.    Mail the  completed form  with  your  changes  to:  Unemployment  Insurance 
Agency, P.O. Box 8086, Royal Oak, MI 48086, or fax it to 1-517-636-0014.
You can also access your MiWAM account to change your address and other account information. 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.: _______________________

Direct any questions to the Office of Employer Ombudsman (OEO) through your MiWAM account at 
www.michigan.gov/uia.  TTY service is available at 1-866-366-0004.

                  *0102520 20 *                                          UIA is an equal opportunity employer/program. 

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