Form Uct-115 12/03 Wisconsin Report Of Business Transfer

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Division of Unemployment Insurance
Report of Business Transfer
P.O. Box 7942, Madison, WI 53707
(Sale/Acquisition/Reorganization)
Telephone: (608) 261-6700
Fax: (608) 267-1400
Under Wisconsin's Unemployment Insurance (UI) Law
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)]. The purpose of this report is to
provide information about changes to the ownership/operators of a business (Section 108.16(8), Wisconsin Statutes). The provision of
your social security number is voluntary. Failure to provide it may result in an information processing delay.
1. Former Owner/Operator
Employer's Legal Name
WI UI Account Number
Telephone Number
(
)
Trade Name
Federal ID Number
Form of Ownership (Check one)
Individual
Limited Partnership
Current Mailing Address (Street or PO Box, City, State, Zip Code)
Partnership
Limited Liability Co
Corporation
Other__________________
Physical Location of Transferred Business
List Names of Partners, Members or Stockholders
Social Security Number
Ownership Percentage of Each
2. New Owner/Operator
Employer's Legal Name
WI UI Account Number
Telephone Number
(
)
Trade Name
Federal ID Number
Form of Ownership (Check one)
Individual
Limited Partnership
Current Mailing Address (Street or PO Box, City, State, Zip Code)
Partnership
Limited Liability Co
Corporation
Other__________________
List Names of Partners, Members or Stockholders
Social Security Number
Ownership Percentage of Each
3. Relationship Between Parties in 1 and 2 Above
Are the parties the same or related (i.e., married; parent/child; common partners/stockholders/officers; parent/subsidiary?
Yes
If Yes, Identify the relationships(s)
No
4. Effective Dates
Date Transfer
MO.
DAY
YR.
Business LAST
MO.
DAY
YR.
Business FIRST
MO.
DAY
YR.
Became
operated by FORMER
operated by NEW
Effective
OWNER/OPERATOR
OWNER/OPERATOR
5. Option for New Owner/Operator
You may have an option to acquire the UI experience of the former owner. An application to
If the date of
You must apply by:
acquire this experience must be filed by the appropriate due date (see chart to the right).
change is:
Check one of the following statements:
Jan. 1 to March 31
July 31
This is an application to acquire the UI account experience.
April 1 to June 30
Oct. 31
New owner does not want to acquire the account experience.
July 1 to Sept. 30
Jan. 31
Request additional information about this option.
Oct. 1 to Dec. 31
April 30
This Form Must Be Completed On Both Sides And Signed Before Mailing
UCT-115 (R. 12/2003)

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