NOTIFICATION OF CHANGE IN FIRM STRUCTURE FORM

 

This change was the result of a:

(please check one)

 

Firm Name Change                  (Complete page 1)

 


Firm Dissolution                      (Complete page 2)

 


Firm Merger                             (Complete page 3)

 

Job class change                       (Complete page 4)

(If you are retired or no longer work in public accounting, please complete page 4)

 

Firm Purchase /Sold                 (Complete page 5)

(If you have sold your firm or purchased another firm, please complete page 5)

 

If none of the above situations applies to your firm change, please explain under separate cover.

 

 

A.     GENERAL INFORMATION:

 

Original Firm Name

 

Original Firm Number                                                                             

 

New Firm Name (s)

 

B. REASON FOR NAME CHANGE: * (If someone left the firm, please complete page 2.  If someone is joining your firm, please fill out page 3.)

 

 

 

 


Effective date of name change __________________________________________________

 

 

Your signature

 


Today’s date

 


FIRM DISSOLUTION

 

 

Effective date of the dissolution

 


Original Firm Name & Address

 

 


*Please list the names and addresses of each resulting firm:

 

Firm 1

Address & Phone

 

 

 


Firm 2

Address & Phone

 

 

 

 


Firm 3

Address & Phone

 

 

 

 

 


Number of partners prior to dissolution

Number of partners after dissolution    Firm 1           Firm 2           Firm 3

 


OF THE FIRMS ORIGINAL ACCOUNTING AND AUDITING HOURS (EXCLUDING TAX OR MCS), WHAT PERCENTAGE DID EACH PARTNER/OWNER FROM THE ORIGINAL FIRM TAKE TO THE NEWLY CREATED FIRM OR TO A CURRENTLY EXISTING FIRM?*

 

Firm 1              %                         Firm 2                 %                              Firm 3            %

(TOTAL MUST EQUAL 100%)

i.e. 

Firm 1  20%                                Firm 2  60%                                     Firm 3  20%

 

*In order to make the appropriate changes, you MUST provide us with all the information needed including where all parties are. (ex. Firm Name, Address, Public or Non-Public) Without this information we will be unable to make the necessary changes.

 

Your signature

 

Today’s date

 

FIRM MERGER

 

 

 

Effective date of the merger

 


*Please list the names and addresses of each merging firm:

 

Firm 1

Address & Phone

 

 

 

 


Firm 2

Address & Phone

 

 

 

 

 


Firm 3

Address & Phone

 

 

 

 

 


Resulting firm name

 

 

OF THE FIRMS ORIGINAL ACCOUNTING AND AUDITING HOURS (EXCLUDING TAX OR MCS), WHAT PERCENTAGE DID EACH PARTNER/OWNER FROM THE ORIGINAL FIRM TAKE TO THE NEWLY CREATED FIRM OR TO A CURRENTLY EXISTING FIRM?*

 

Firm 1              %                         Firm 2        %                                       Firm 3           %

(TOTAL MUST EQUAL 100%)

i.e.

Firm 1  20%                                Firm 2  60%                                     Firm 3  20%

      

*In order to make the appropriate changes, you MUST provide us with all the information needed including where all parties are. (ex. Firm Name, Address, Public or Non-Public) Without this information we will be unable to make the necessary changes.

 

Your signature

 

Today’s date

 

 

 

CURRENTLY WORKING IN INDUSTRY OR RETIRED

 

 

 

 

 

If you no longer work in public accounting please provide the name & address of your present employer below:

 

 

 

 

 

 

 

 

 

 If you are retired, please provide the following information:

 

 

Date of retirement

 

 


Current mailing address

 

 

 

 

 

 

 

 

 


Your signature

 

Today’s date

 

 

FIRM PURCHASED/FIRM SOLD

 

 

 

 

Effective date of firm purchase

 

 

Name & address of the firm that

purchased your firm

 

 

 

 

 

 

 


                                                                            *Are you working for this firm? If yes, in what capacity?

                            If you are working for this firm as a partner, THEN YOU                              MUST FILL OUT PAGE 3 – FIRM MERGER)                   

                                                                            ____________________________________________

 

                                                                            _____________________________________________

                                                                            

                                                                            If no, please complete information below:

                                                                                                                

                                                                           Name _________________________________________

                                                                                               

   Company Name ________________________________

 

                                                                           Address _______________________________________

 

                                                                             _____________________________________________

                                                                           

                                                                            *Job Function__________________________________      

 

Your signature

 


Today’s date                                                      ___________________________________________

 

 

*If you were a partner/owner of the original firm, and you will be a partner/owner with the new firm, then you MUST fill out page 3.

 

(Please note–If this form is not filled out correctly, it will delay the process and as a result, no changes will be made. If you need assistance in filling out this form, please call your administering state society or the AICPA Peer Review Division at (201) 938-3030.