1025 Uia UC1025 76085 7
User Manual: 1025
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* The Power of Attorney on le is responsible for all mailing to a representative. The address of a representative should not be on this name/address form.
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 le Form UIA 1772, Notice of Change
You may submit Form UIA 1772 through your MiWAM account or you may download and print the form, and mail the completed
address shown below.
You can also access your MiWAM account to change your address and other account information. Other changes, including
FEIN changes or bankruptcy ling, 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.: _______________________
Mail this form with your changes and documentation to: Unemployment Insurance, PO Box 8086, Royal Oak,
MI 48086, or fax to (313) 456-2130. If you need assistance, telephone 1-855-484-2636.
TTY customers call 1-866-366-0004.
TED is an equal opportunity employer/program.
Employer Request for Name/Address Change
Current or Former Employer Name: ______________________________________________
UI Employer Account No.:_______________ Federal Employer ID No. (FEIN):________________
New Employer Name: ______________________________________________________________
DBA: ___________________________________________________________________________
E-Mail Address: ___________________________________________________________________
DO NOT SUBMIT THIS FORM UNLESS THERE HAS BEEN A CHANGE IN NAME AND/OR ADDRESS.*
Physical Michigan Location of the Business
(No Post Ofce Boxes) Mailing Address
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 Ofce Owner
STATE OF MICHIGAN
RICK SNYDER DEPARTMENT OF TALENT AND ECONOMIC DEVELOPMENT ROGER CURTIS
GOVERNOR TALENT INVESTMENT AGENCY DIRECTOR
UNEMPLOYMENT INSURANCE WANDA M. STOKES
DIRECTOR
UIA 1025
(Rev. 09-17)
Authorized by
MCL 421.1 et seq. •
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