Maryland Unemployment Insurance - Business Transfer Report Form

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Maryland Unemployment Insurance – Business Transfer Report
File this report when workforce/payroll has been transferred from one business entity to another business
entity for any reason such as a business acquisition, merger, reorganization or change of legal entity.
Attach additional pages whenever multiple business entities are involved, or additional space is needed.
Label information as pertaining to the previous or successor business entity. Return this completed report
by mail to Employer Status Unit, 1100 N. Eutaw Street, Room 409, Baltimore, Maryland 21201; or via fax
to 410-767-2848 or as an email attachment to status@dllr.state.md.us
Previous Business Entity Information:
Legal name ____________________________________________________________________________
Maryland unemployment insurance account number _______________________FEIN________________
Does previous business entity expect to pay wages to employees after date of transfer?
[ ] Yes [ ] No
If no, enter date wages last paid to employees ________________________________________________
According to the Chart of Principals by Business Entity, list the name(s) of principal(s) for the previous
business entity
________________________
_______________________
___________________________
_________________________
_______________________
____________________________
Chart of Principals by Business Entity:
1. If business entity is sole proprietor, list the sole proprietor’s name
2. If business entity is partnership, list the partners’ names
3. If business entity is a limited liability company, list the members’ names
4. If business entity is a corporation, list the Chief Executive Officer, Chief Financial Officer and all
corporate officers responsible for daily operations
Successor Business Entity Information:
Legal Name ___________________________________________________________________________
Maryland unemployment insurance account number __________________FEIN ___________________
Percentage of previous business entity’s workforce/payroll transferred to successor business entity _______
Enter date that previous business entity’s workforce/payroll was acquired __________________________
Did successor business entity acquire any assets from the previous business entity?
[ ] Yes
[ ] No
According to the Chart of Principals by Business Entity, list name(s) of principal(s) for the successor
business entity
______________________
_______________________
__________________________
_______________________
________________________
___________________________
Has successor entity completed a Combined Registration Application? [ ] Yes [ ] No
If answer is no, please complete the Combined Registration Application at
Name, Signature and Title of Person who completed this Form:
Name __________________________________ Signature ___________________________________
Title ____________________________________ Date _______________________________________

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