Application And Agreement For Partial Transfer Of Experience Rating Record Form - Louisiana Department Of Labor
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2APPLICATION AND AGREEMENT FOR PARTIAL TRANSFER OF EXPERIENCE RATING RECORD
Complete this form only if your account acquired a portion of an existing business.
This application is due 180 days from the date of the partial acquisition and furnishes information needed to secure
a partial transfer of experience rating records. If approved, the partial successor will receive the indicated taxable
payroll for the transferred employees as listed herein. These amounts will be deducted from the taxable payroll of
the partial predecessor for the same periods. Also, the successor will receive the indicated percentage of the
predecessor’s reserve, benefit charges, and contributions for the fiscal year ending immediately prior to the
segregation year, and for the interim quarters up to the segregation date. Likewise, these amounts will be deducted
from the predecessor’s experience rating records for the same period.
1.
2.
Successor (Buyer)
Predecessor (Seller)
Account No. __________________________________
Account No. _____________________________________
Business Name ________________________________
Business Name ___________________________________
Address _____________________________________
Address ________________________________________
City, State, Zip ________________________________
City, State, Zip ___________________________________
3. Date “segregable and identifiable portion” of organization, trade, or business transferred: Mo/Day/Yr
________
4. Law requires that employers involved advise the Agency of the percentage of transfer. This percentage must
be agreed upon by both employers. One method of calculating the percentage of transfer is as follows. To
calculate the percentage of experience rating records to be transferred, list below the amount of taxable payroll
(not total payroll) by fiscal year (not calendar year) related to the transferred portion of the business. It should
be listed for the three completed fiscal years ending immediately prior to the segregation year. For example, if
segregation occurred anytime in 2004, the taxable payrolls for fiscal years ending 6/03, 6/02, and 6/01 should
be provided. If both employers agree on a percentage without actually dividing the transferred taxable payroll
by the predecessor’s taxable payroll, only complete the percentage blank below. That percentage will be used to
transfer the predecessor’s experience rating records to the successor’s account.
Taxable Payroll of Employees of Transferred Portion
Taxable Payroll of all Employees of the Predecessor
Successor No. _________________________
Predecessor No. _______________________
F/Y ending 6/30/_____
$_____________________
F/Y ending 6/30/_____
$_____________________
F/Y ending 6/30/_____
$_____________________
F/Y ending 6/30/_____
$_____________________
F/Y ending 6/30/_____
$_____________________
F/Y ending 6/30/_____
$_____________________
0.00
0.00
Total all quarters
$_____________________
Total all quarters
$_____________________
Transferred Portion Taxable Payroll Total
--------------------------------------------------- = Percentage of Data Transferred __________ %
Predecessor’s Taxable Payroll Total
5. We, the predecessor and successor employers, mutually consent to and hereby request the transfer of the
“segregable and identifiable portion” of the predecessor’s experience rating record, related to the transferred
portion of the business, in accordance with Employment Security Law. Furthermore, we do hereby jointly
certify that the information provided herein and on supplement(s) is true to the best of our knowledge and
belief.
SUCCESSOR
PREDECESSOR
___________________________________________ Signature_______________________________________________
___________________________________________ Title___________________________________________________
___________________________________________ Date Signed_____________________________________________
(_______) __________________________________ Telephone # (_______) ___________________________________
Rev 3/04
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