This form contains 99 fields organized into 20 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Address Change Information
Address Change Date Month Text
Enter the month of the effective date for the address change.
Max length: 2 characters
Address Change Date Day Text
Enter the day of the effective date for the address change.
Max length: 2 characters
Address Change Date Year Text
Enter the year of the effective date for the address change.
Max length: 4 characters
Address Change Street Address Text
Provide the new street number and name for the updated business address.
Max length: 60 characters
Address Change City, State, Zip Text
Provide the new city, state, and zip code for the updated business address.
Max length: 33 characters
Address Change Phone Number Part 1 Text
Enter the first component of the new phone number associated with the business.
Max length: 3 characters
Address Change Phone Number Part 2 Text
Enter the second component of the new phone number associated with the business.
Max length: 10 characters
Business Name (DBA) Change
New Business Name (DBA) Text
Please enter the new Business Name (DBA).
Max length: 35 characters
Date of Change Month Text
Please enter the month the Business Name (DBA) was changed.
Max length: 2 characters
Date of Change Day Text
Please enter the day the Business Name (DBA) was changed.
Max length: 2 characters
Date of Change Year Text
Please enter the year the Business Name (DBA) was changed.
Max length: 4 characters
Change of Ownership Information
Change of Ownership Month Date
Enter the month corresponding to the change of ownership date.
Max length: 2 characters
Change of Ownership Day Text
Enter the day corresponding to the change of ownership date.
Max length: 2 characters
Change of Ownership Year Number
Enter the year corresponding to the change of ownership date.
Max length: 4 characters
Partial Sale, Not Out-Of-Business Checkbox
Check this box if there was a partial sale of the business, but the business is not entirely out of operation.
Entire Business Sold Checkbox
Check this box if the entire business was sold, and provide successor information in Box 2.
Corporation Dissolved Checkbox
Check this box if the corporation has been dissolved.
Other (Explain) Checkbox
Check this box if the change of ownership is not covered by the other options, and provide an explanation.
Other Explanation Text
Provide a detailed explanation if 'Other' is selected as the reason for the change of ownership. Fill only if 'Other (Explain)' is 'Yes'.
Max length: 40 characters
Depends on: Other (Explain)
Corporation Formed Checkbox
Check this box if a new corporation has been formed.
Change in Ownership Type Checkbox
Check this box if there was a change in the type of ownership, and provide details in Box 2 and explain the type.
Purchase Price $ Checkbox
Check this box when the change of ownership was a purchase transaction and you need to report the purchase price amount.
Purchase Price Number
Enter the purchase price if the 'Purchase Price' option is selected for the change of ownership. Fill only if 'Partial Sale, Not Out-Of-Business', 'Entire Business Sold' is 'Yes', any.
Max length: 12 characters
Depends on: Partial Sale, Not Out-Of-Business, Entire Business Sold
Corporation Name Change
New Corporation Name Text
Enter the new legal name of the corporation.
Max length: 39 characters
Month of Change Date
Enter the month when the corporation name change took effect.
Max length: 2 characters
Day of Change Date
Enter the day when the corporation name change took effect.
Max length: 2 characters
Year of Change Date
Enter the year when the corporation name change took effect.
Max length: 4 characters
Date of Last Wage Payment
Month of Last Wage Payment Date
Please enter the month of the last wage payment.
Max length: 2 characters
Day of Last Wage Payment Date
Please enter the day of the last wage payment.
Max length: 2 characters
Year of Last Wage Payment Date
Please enter the year of the last wage payment.
Max length: 4 characters
Employer Account Information
EDD Account Number Text
Please enter the Employment Development Department (EDD) account number.
Max length: 10 characters
Corporation/Owner's Name Text
Please enter the name of the corporation or the owner.
Max length: 30 characters
Business Name (DBA) Text
Please enter the legal business name, including any 'Doing Business As' (DBA) name.
Max length: 31 characters
Banking Institution Text
Please enter the name of the banking institution associated with the account.
Max length: 26 characters
First Owner Following Change
Owner's Name Text
Provide the full legal name of the owner following the change of ownership. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 52 characters
Depends on: Entire Business Sold, Change in Ownership Type
Owner's Title Text
Enter the official title of the owner. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 20 characters
Depends on: Entire Business Sold, Change in Ownership Type
Business Name (DBA) / Corporation Name Text
Provide the business name (DBA) or the corporation name associated with the owner. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 54 characters
Depends on: Entire Business Sold, Change in Ownership Type
Mailing Address Text
Enter the full mailing address for the owner. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 52 characters
Depends on: Entire Business Sold, Change in Ownership Type
First Partner/Officer Change
Add Partner/Officer Checkbox
Check this box if you are adding a new partner, officer, member, or manager to the business.
Change Partner/Officer Checkbox
Check this box if you are changing information for an existing partner, officer, member, or manager.
Delete Partner/Officer Checkbox
Check this box if you are deleting an existing partner, officer, member, or manager from the business.
Date of Change Month Date
Enter the month of the partner or officer change. Fill only if 'Add Partner/Officer', 'Change Partner/Officer', 'Delete Partner/Officer' is 'Yes', any.
Max length: 2 characters
Depends on: Add Partner/Officer, Change Partner/Officer, Delete Partner/Officer
Date of Change Day Text
Enter the day of the partner or officer change. Fill only if 'Add Partner/Officer', 'Change Partner/Officer', 'Delete Partner/Officer' is 'Yes', any.
Max length: 2 characters
Depends on: Add Partner/Officer, Change Partner/Officer, Delete Partner/Officer
Date of Change Year Text
Enter the year of the partner or officer change. Fill only if 'Add Partner/Officer', 'Change Partner/Officer', 'Delete Partner/Officer' is 'Yes', any.
Max length: 4 characters
Depends on: Add Partner/Officer, Change Partner/Officer, Delete Partner/Officer
Individual's Name Text
Enter the name of the individual to be added, changed, or deleted. Fill only if 'Add Partner/Officer', 'Change Partner/Officer', 'Delete Partner/Officer' is 'Yes', any.
Max length: 54 characters
Depends on: Add Partner/Officer, Change Partner/Officer, Delete Partner/Officer
Individual's Title Text
Enter the title of the individual. Fill only if 'Add Partner/Officer', 'Change Partner/Officer', 'Delete Partner/Officer' is 'Yes', any.
Max length: 10 characters
Depends on: Add Partner/Officer, Change Partner/Officer, Delete Partner/Officer
Social Security Number Text
Enter the Social Security Number of the individual. Fill only if 'Add Partner/Officer', 'Change Partner/Officer', 'Delete Partner/Officer' is 'Yes', any.
Max length: 11 characters
Depends on: Add Partner/Officer, Change Partner/Officer, Delete Partner/Officer
Driver's License Number Text
Enter the Driver's License Number of the individual. Fill only if 'Add Partner/Officer', 'Change Partner/Officer', 'Delete Partner/Officer' is 'Yes', any.
Max length: 13 characters
Depends on: Add Partner/Officer, Change Partner/Officer, Delete Partner/Officer
No Wages Paid Quarter
No Wages Paid Quarter Text
Please enter the appropriate year and quarter during which no wages were paid, using the YYYY/Q format.
Max length: 70 characters
Out of Business Date
Out of Business Month Date
Enter the month the business ceased operations.
Max length: 2 characters
Out of Business Day Text
Enter the day the business ceased operations.
Max length: 2 characters
Out of Business Year Text
Enter the year the business ceased operations.
Max length: 4 characters
Personal Name Change
Personal Name Text
Enter the new personal name of the individual (e.g., after marriage).
Max length: 30 characters
Change Date Month Text
Enter the two-digit month (MM) when the personal name change occurred.
Max length: 2 characters
Change Date Day Text
Enter the two-digit day (DD) when the personal name change occurred.
Max length: 2 characters
Change Date Year Text
Enter the four-digit year (YYYY) when the personal name change occurred.
Max length: 4 characters
Phone Number
Phone Number Area Code Text
Provide the three-digit area code for the phone number.
Max length: 3 characters
Phone Number Local Number Text
Provide the local part of the phone number.
Max length: 8 characters
Professional Employer Organization Information
PEO Name Text
Enter the name of the Professional Employer Organization.
Max length: 75 characters
PEO Address Text
Enter the full mailing address of the Professional Employer Organization.
Max length: 73 characters
PEO EDD Account Number Text
Enter the EDD Account Number assigned to the Professional Employer Organization.
Max length: 10 characters
PEO Start Date Date
Enter the date when the Professional Employer Organization started providing services.
Max length: 23 characters
Second Owner Following Change
Second Owner Name Text
Provide the full name of the owner(s) following the change of ownership. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 52 characters
Depends on: Entire Business Sold, Change in Ownership Type
Second Owner Title Text
Enter the title of the second owner following the change of ownership. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 20 characters
Depends on: Entire Business Sold, Change in Ownership Type
Second Owner Business Name (DBA)/Corporation Name Text
Provide the business name (DBA) or corporation name of the second owner following the change of ownership. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 54 characters
Depends on: Entire Business Sold, Change in Ownership Type
Second Owner Mailing Address Text
Enter the mailing address of the second owner following the change of ownership. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 52 characters
Depends on: Entire Business Sold, Change in Ownership Type
Second Partner/Officer Change
Add Partner/Officer Checkbox
Check this box if you are adding a new partner, officer, member, or manager.
Change Partner/Officer Checkbox
Check this box if you are changing the information for an existing partner, officer, member, or manager.
Delete Partner/Officer Checkbox
Check this box if you are deleting an existing partner, officer, member, or manager.
Change Date (Month) Text
Enter the numeric month of the change for the partner, officer, member, or manager. Fill only if 'Add Partner/Officer', 'Change Partner/Officer', 'Delete Partner/Officer' is 'Yes', any.
Max length: 2 characters
Depends on: Add Partner/Officer, Change Partner/Officer, Delete Partner/Officer
Change Date (Day) Text
Enter the numeric day of the change for the partner, officer, member, or manager. Fill only if 'Add Partner/Officer', 'Change Partner/Officer', 'Delete Partner/Officer' is 'Yes', any.
Max length: 2 characters
Depends on: Add Partner/Officer, Change Partner/Officer, Delete Partner/Officer
Change Date (Year) Date
Enter the numeric year of the change for the partner, officer, member, or manager. Fill only if 'Add Partner/Officer', 'Change Partner/Officer', 'Delete Partner/Officer' is 'Yes', any.
Max length: 4 characters
Depends on: Add Partner/Officer, Change Partner/Officer, Delete Partner/Officer
Individual Name Text
Enter the full name of the partner, officer, member, or manager being added, changed, or deleted. Fill only if 'Add Partner/Officer', 'Change Partner/Officer', 'Delete Partner/Officer' is 'Yes', any.
Max length: 54 characters
Depends on: Add Partner/Officer, Change Partner/Officer, Delete Partner/Officer
Individual Title Text
Enter the title of the partner, officer, member, or manager. Fill only if 'Add Partner/Officer', 'Change Partner/Officer', 'Delete Partner/Officer' is 'Yes', any.
Max length: 10 characters
Depends on: Add Partner/Officer, Change Partner/Officer, Delete Partner/Officer
Social Security Number Text
Enter the Social Security Number of the partner, officer, member, or manager. Fill only if 'Add Partner/Officer', 'Change Partner/Officer', 'Delete Partner/Officer' is 'Yes', any.
Max length: 11 characters
Depends on: Add Partner/Officer, Change Partner/Officer, Delete Partner/Officer
Driver's License Number Text
Enter the Driver's License Number of the partner, officer, member, or manager. Fill only if 'Add Partner/Officer', 'Change Partner/Officer', 'Delete Partner/Officer' is 'Yes', any.
Max length: 13 characters
Depends on: Add Partner/Officer, Change Partner/Officer, Delete Partner/Officer
Signatory Details
Signatory Name Text
Please provide the printed name of the person signing this document.
Max length: 40 characters
Signatory Title Text
Please provide the title or role of the signatory, such as Officer, Owner, Member, General Partner, or Authorized Agent.
Max length: 40 characters
Signature Date
Signature Date Month Date
Enter the month of the signature.
Max length: 2 characters
Signature Date Day Date
Enter the day of the signature.
Max length: 2 characters
Signature Date Year Date
Enter the year of the signature.
Max length: 4 characters
Tax and Legal Identification
New FEIN (Tax ID) Text
Enter the new Federal Employer Identification Number. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 10 characters
Depends on: Entire Business Sold, Change in Ownership Type
Old FEIN (Tax ID) Text
Enter the previous Federal Employer Identification Number. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 10 characters
Depends on: Entire Business Sold, Change in Ownership Type
Reason for New Tax ID Text
Provide a detailed explanation for why a new Federal Employer Identification Number is being requested. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 36 characters
Depends on: Entire Business Sold, Change in Ownership Type
SOS Corporation, LLC, LLP, or LP Identification Number Text
Enter the identification number assigned by the Secretary of State for the Corporation, LLC, LLP, or LP. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 12 characters
Depends on: Entire Business Sold, Change in Ownership Type
Third Owner Following Change
New FEIN (Tax ID) Text
Provide the new Federal Employer Identification Number (Tax ID) that applies to the entity after the ownership change. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 52 characters
Depends on: Entire Business Sold, Change in Ownership Type
Third Owner Title Text
Enter the title (e.g., President, CEO, Partner) of the third owner listed following the change of ownership. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 20 characters
Depends on: Entire Business Sold, Change in Ownership Type
Old FEIN (Tax ID) Text
Provide the previous Federal Employer Identification Number (Tax ID) that applied to the entity before the ownership change. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 54 characters
Depends on: Entire Business Sold, Change in Ownership Type
SOS Identification Number Text
Enter the identification number assigned by the Secretary of State (SOS) for the Corporation, LLC, LLP, or LP involved in the ownership change. Fill only if 'Entire Business Sold', 'Change in Ownership Type' is 'Yes', any.
Max length: 52 characters
Depends on: Entire Business Sold, Change in Ownership Type
Third Partner/Officer Change
Add Third Partner/Officer Checkbox
Check this box if you are adding a third partner, officer, member, or manager to the business.
Change Third Partner/Officer Checkbox
Check this box if you are changing the information for a third partner, officer, member, or manager.
Delete Third Partner/Officer Checkbox
Check this box if you are deleting a third partner, officer, member, or manager from the business.
Third Partner Change Date Month Date
Enter the month of the date when the third partner or officer was added, changed, or deleted. Fill only if 'Add Third Partner/Officer', 'Change Third Partner/Officer', 'Delete Third Partner/Officer' is 'Yes', any.
Max length: 2 characters
Depends on: Add Third Partner/Officer, Change Third Partner/Officer, Delete Third Partner/Officer
Third Partner Change Date Day Text
Enter the day of the date when the third partner or officer was added, changed, or deleted. Fill only if 'Add Third Partner/Officer', 'Change Third Partner/Officer', 'Delete Third Partner/Officer' is 'Yes', any.
Max length: 2 characters
Depends on: Add Third Partner/Officer, Change Third Partner/Officer, Delete Third Partner/Officer
Third Partner Change Date Year Text
Enter the year of the date when the third partner or officer was added, changed, or deleted. Fill only if 'Add Third Partner/Officer', 'Change Third Partner/Officer', 'Delete Third Partner/Officer' is 'Yes', any.
Max length: 4 characters
Depends on: Add Third Partner/Officer, Change Third Partner/Officer, Delete Third Partner/Officer
Third Partner Individual Name Text
Enter the full name of the third partner or officer to be added, changed, or deleted. Fill only if 'Add Third Partner/Officer', 'Change Third Partner/Officer', 'Delete Third Partner/Officer' is 'Yes', any.
Max length: 54 characters
Depends on: Add Third Partner/Officer, Change Third Partner/Officer, Delete Third Partner/Officer
Third Partner Title Text
Enter the title of the third partner or officer. Fill only if 'Add Third Partner/Officer', 'Change Third Partner/Officer', 'Delete Third Partner/Officer' is 'Yes', any.
Max length: 10 characters
Depends on: Add Third Partner/Officer, Change Third Partner/Officer, Delete Third Partner/Officer
Third Partner Social Security Number Text
Enter the social security number of the third partner or officer. Fill only if 'Add Third Partner/Officer', 'Change Third Partner/Officer', 'Delete Third Partner/Officer' is 'Yes', any.
Max length: 11 characters
Depends on: Add Third Partner/Officer, Change Third Partner/Officer, Delete Third Partner/Officer
Third Partner Driver's License Number Text
Enter the driver's license number of the third partner or officer. Fill only if 'Add Third Partner/Officer', 'Change Third Partner/Officer', 'Delete Third Partner/Officer' is 'Yes', any.
Max length: 13 characters
Depends on: Add Third Partner/Officer, Change Third Partner/Officer, Delete Third Partner/Officer