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UIA 1772 Authorized by
(Rev. 09-17) MCL 421.1 et seq.

STATE OF MICHIGAN •
RICK SNYDER DEPARTMENT OF TALENT AND ECONOMIC DEVELOPMENT ROGER CURTIS
GOVERNOR TALENT INVESTMENT AGENCY DIRECTOR
UNEMPLOYMENT INSURANCE RESET FORMWANDA M. STOKES
DIRECTOR
Notice of Change
Information shown on this report is used to determine termination of liability under Section 24 of the Michigan Employment
Security (MES) Act. Completion of this report is required even though you may not be currently employing any
workers. Failure to provide this information may result in a determination being made based on information available
to Unemployment Insurance. Penalties may be imposed under Section 54(a) or 54(b) of the MES Act for an intentional
failure to comply with State law.

PART I: EMPLOYER INFORMATION

1. Current name and address.
a. Name: ___________________________________ Employer Account Number (EAN): ____________
b. Mailing Address: ____________________________________________________________________
c. Telephone: __________________________ Federal Employer ID (FEIN): _________________

2. Provide the following information concerning the owner(s), partners, corporate officers, LLC
member(s), etc., of the organization and the person(s) who safeguard the company’s books and
records. If necessary, please attach additional pages to provide information on all owners.

a. Name: _________________________________ SSN: _________________ Birth Date: ___________
Address: ___________________________________________________________________________
Title: ______________________________Telephone: ______________ Record Holder: Yes No

b. Name: _________________________________ SSN: _________________ Birth Date: ___________
Address: ___________________________________________________________________________
Title: ______________________________Telephone: ______________ Record Holder: Yes No

c. Name:_________________________________ SSN:__________________ Birth Date: ____________
Address: ___________________________________________________________________________
Title: ______________________________Telephone: ______________ Record Holder: Yes No

3. Reason(s) for discontinuance or transfer of payroll or assets in whole or part (check one or more).

Sale Reorganization New Partnerships
Lease Bankruptcy Incorporation
Foreclosure Dissolution/Discontinuance No Employees
Merger Death
Other (explain):

4. Provide the following information:
a. Date of last payroll: ______________________

5. Provide the following information:
a. Did you discontinue all employment in Michigan? Yes No
If no, how many employees were retained? ______
b. Have you continued or resumed business in Michigan? Yes No

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UIA 1772
(Rev. 09 -17)
Page 2
If you answered yes to question #5, complete the section below if the information differs from what
was provided in question #1.
___________________________________ __________________________________________
Legal Name of Business Address

___________________________________ __________________________________________
Nature of Business Date(s) Resumed Business

Complete Part II and Part III only if your business was sold or transferred.
PART II: NEW OWNER INFORMATION
Please provide the name(s) of the person(s)who acquired the Michigan assets, Michigan organization,
Michigan trade, or Michigan business. “Acquired” refers not only to assets purchased, but also assets
acquired by rental, lease, use, inheritance, merger, mortgage, foreclosure, gift, or other transfer. If more
than one individual or organization is involved, answer all parts of this question for each purchaser,
using separate sheets. If preferred, additional forms will be supplied upon request.
New Owner’s Name New Owner’s UI Account Number or FEIN, if known.

New Corporation Name or DBA Area Code & Telephone Number

Current Street Address (No PO Box)

City, State, Zip Code

PART III: ACQUISITION INFORMATION:

Complete this section carefully. It might be necessary to consult your accountant, attorney, or financial
advisor for a complete valuation of your entire business to accurately determine the percentage of
transfer for each item below.
All Part None What Date
1. Did the above acquire all, part, or none of the assets Percentage Acquired
of any former business? ________% _______

a. Number of business location in Michigan:

b. Number of business location in Michigan that have
been discontinued:
All Part None
2. Did the above acquire all, part, or none of the organization
(employees/payroll/personnel) of any former business?
What Date
Percentage Acquired
a. If all or part, indicate the percent and date acquired
________% ________
b. Did the above acquire all or part of the Yes No If yes, provide a copy of your
employees/payroll/personnel of any former business lease agreement.
by leasing any of those employee/payroll/personnel?
All Part None What Date
3. Did the above acquire all, part, or none of the trade percentage Acquired
(customers/accounts/clients) of any former business? _______% ________
What Date
4. Did the above acquire all, part, or none of the former All Part None percentage Acquired
owner’s Michigan business (products/services) of any
_______% ________
former business?

5. Was your Michigan business described in 1-4 above
Yes No Date operation ended
being operated at the time of acquisition? If no, enter
the date it ceased operation. __________________

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UIA 1772
(Rev. 09-17)
Page 3
6. Is the above conducting/operating the Michigan business Yes No
acquired from you?

7. Is the above substantially owned, merged, or controlled If Yes, continue using this
Yes No
in any way by the same interests who owned or form.
controlled the organization, business or assets of If No, ask for Schedule B.
your business?
Yes No If Yes, enter balance owed
8. Did the above hold any secured interest in any of the
Michigan assets acquired from you? $______________
9. Enter the reasonable value of the Michigan organization,
trade, business or assets sold or transferred. $______________

CERTIFICATION

I certify that the information contained in this report is accurate and complete
to the best of my knowledge and belief. I understand that if I fail to provide
accurate and complete information on this form, I may be subject to penalties
of up to four times the amount of resulting unpaid unemployment taxes and
imprisonment for up to five years.

____________________________________ ______________________
Name Date

____________________________________ _______________________
Title Telephone Number

When a complete transfer of a Michigan business is involved:
• Your final Quarterly Wage/Tax Report must be filed and paid within 15 days,
• Your coverage will be terminated as of the transfer date,
• If you have persons in your employ after the transfer date of your business, you need to
notify Unemployment Insurance immediately to determine if you are liable for taxes on
that payroll.

When a partial transfer of a Michigan business is involved:
• You need to continue to report and pay taxes if you have Michigan workers in your
employ or until your coverage is terminated.

All documents, agreements or records describing the transactions indicated in Part I Item 4, Part
II and Part III above, should be kept available for examination by Unemployment Insurance for six
years.

You may submit this Form through your Michigan Web Account Manager (MiWAM) account or via
fax to 1-313- 456-2130. If you are mailing this form, please send it to Unemployment Insurance, Tax
Office, PO Box 8068, Royal Oak, Michigan 48068-8068

If you have any questions, contact the Office of Employer Ombudsman (OEO) by email at OEO@
michigan.gov or at 1-855-4UIAOEO (855-484-2636), or 313-456-2300. TTY customers call 1-866-
366-0004.

TED is an equal opportunity employer/program.

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