Application And Agreement For Partial Transfer Of Experience Rating Record Form - Louisiana Workforce Commission
Download a blank fillable Application And Agreement For Partial Transfer Of Experience Rating Record Form - Louisiana Workforce Commission in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Application And Agreement For Partial Transfer Of Experience Rating Record Form - Louisiana Workforce Commission with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2APPLICATION AND AGREEMENT FOR
PARTIAL TRANSFER OF EXPERIENCE RATING RECORD
Mandatory for Partial Successions
Louisiana Employment Security Law Title 23:1539 & 23:1539.1
Complete this form only if your account acquired a portion of an existing business. If you acquired 100% of another
business, this application does NOT need to be completed.
The partial successor record will receive the taxable payroll for the transferred employees as listed herein. The
successor will also 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 partial predecessor’s experience rating record for the same period.
1. Successor (Buyer)
2. 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: M/D/Y ____/____/____.
4. The LA Employment Security Law requires employers involved in a partial succession to advise the Agency of the
percentage of transfer. Both employers must agree on this percentage. The percentage will be used to transfer a
portion of the predecessor’s experience rating record to the successor’s account.
Transferred Portion of 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
Signature
_______________________________________
_______________________________________
Title
Title
_______________________________________
_______________________________________
Date
Date
_______________________________________
_______________________________________
Telephone No. & Ext.
Telephone No. & Ext.
This form must be returned by ___________________. If you fail to return this form by the date indicated, the
Agency/Administrator may perform an audit to determine the percentage of taxable payroll, reserve,
contributions and benefit charges that will be transferred to the partial successor.
PART TRANS APP web (REV 6/09)
1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application And Agreement For Partial Transfer Of Experience Rating Record Form - Louisiana Department Of Labor
Legal
Form Application And Agreement For Partial Transfer Of Experience Rating Record - Louisiana Department Of Labor
Legal
Form Ucs-1s - Report To Determine Succession And Application For Transfer Of Experience Rating Records - Florida Department Of Revenue
Legal
Form Rts-1s - Report To Determine Succession And Application For Transfer Of Experience Rating Records 2015
Financial
Form Ucs-1s - Report To Determine Succession And Application For Transfer Of Experience Rating Records
Financial
Form Ucs-1s - Report To Determine Succession And Application For Transfer Of Experience Rating Records
Financial
Form Rts-1s - Report To Determine Succession And Application For Transfer Of Experience Rating Records
Financial
Form Rts-1s - Report To Determine Succession And Application For Transfer Of Experience Rating Records
Financial
Related Categories
Parent category: Legal