Out of Business Notification

Out of Business Notification
Account Number*
Name of Firm / Owner
Business Name*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you have discontinued or sold your business, complete this form and include a copy with your final report.
If discontinued, state whether:

TemporaryPermanent
If Temporarily discontinued, Provide Closing & Reopening Dates
If Permanently discontinued, Provide discontinued Date

MonthDayYear
Date
If Permanently Discontinued, Provide Disposition of Assets

MovedSoldRetained
If sold, provide purchaser's name and address below
Purchaser's Name
Purchaser's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Purchaser's Email Address
example@example.com
Purchaser's Phone Number

Area CodePhone Number
Please Sign and Date Below:
** Notification must be signed by the owner of the business; or if a partnership, by a partner; or if a corporation, by an authorized officer.
Your Title
Authorized Signer's Name

First NameMiddle NameLast Name
Date

MonthDayYear
Date
SIGNATURE

Clear
Should be Empty: