MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS                                        OFFICE USE ONLY 
                    DIVISION OF EMPLOYMENT SECURITY 
                    P.O. Box 59, Jefferson City, MO 65104-0059        Fax:  573-751-7483                    A / N       
                    REPORT ON CHANGE OF BUSINESS OPERATIONS                                                 L I A 9          - I D    
               
EMPLOYER NAME (Print)                                                                         Account  Number        
                      Please complete item(s) which apply to you and print name below.  Mail or fax to the above address. 
I.   COMPLETE THIS SECTION IF EMPLOYMENT/BUSINESS WAS DISCONTINUED AND BUSINESS WAS NOT SOLD 
     A.   Enter the date or quarter and year you last paid wages to either part-time or full-time workers              
 B. operatingIfas a corporation, do/will officers receive any type of compensation?                    Yes        No 
          If  answer  is  “Yes,”  explain       
 C.  you anticipateDo employing workers in the foreseeable future?               Yes       No      Date Anticipated         
          If answer is “Yes,” expl a i n        
  (A “Yes” answer will allow your account to continue as “Active.”  A “No” answer will be considered an application for exemption from 
          filing contribution & wage reports beginning with quarter following last date you paid wages.)
     D.   Check the reason you no longer pay wages: 
              Closed business.  Enter date business was closed                    Reason  closed       
              Operate business without help.  Explain   
              Use independent contractors/contract labor. Provide names, trade names, addresses and phone numbers of each. Submit copies of 
              invoices, business cards and any other documentation you have. 
                    
              Bankruptcy      Case Number                      C o u r t                 D a t e   F i l e d     Chapter 
              Death of sole proprietor       Date of Death                                 Letters of Refusal of Probate 
                    Probate    County                                             C a s e   N u m b e r          
   Name & Address of Personal Representative
              IF BANKRUPT OR PROBATE: Name & Address of Attorney               
   
              Employees leased. Who provides the employee leasing services to your business?  (State name, address & phone number of leasing 
              company and submit copy of employee leasing agreement.)            

              Other  reason        
     E.   What, if any, assets remain?        
II.  COMPLETE THIS SECTION TO SHOW CHANGE IN OWNERSHIP OF THE BUSINESS 
     A.   Date of change                                            
     B.   Indicate the type of change. 
     Entire Business Sold                                       Change in Partnership                                     Merger 
     Corporation/LLC Formed or Dissolved                        Stock Ownership Change (Provide list of officers) 
      Other  Change,  explain        
     Partial Sale Only – Explain what portion(s) of business was acquired and the percentage of total business acquired.
                     
    What  you still operate?       do 
     C.   Enter new owner’s name, business name, address, telephone number and Federal ID Number            

     D.   Does the new operator have common ownership, management or control with the previous operator?                  Yes         No
          If  yes,  please  explain        
 E. Were services performed after the date you stated in Item II.A.?         Yes         No
          If “Yes,” explain              

     F.   What, if any, assets remain?        
III.  ADDRESS AND/OR BUSINESS/TRADE NAME AND/OR TELEPHONE NUMBER CHANGES 
          Employer address change.  New address is             
          Business/trade name change   t o       
         Telephone number change   t o         
I certify that the information supplied on this form is true and correct to the best of my knowledge and understanding. 
Name (Print)                                                                     Title       
Telephone  Number                                                                Date       
 
                                                                                                                                      MODES-9 (11-09)  AI 
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