UCS-1S
R. 10/00
Report to Determine Succession and Application for Transfer
of Experience Rating Records
IF YOU PURCHASE OR LEASE AN EXISTING BUSINESS, IN WHOLE OR IN PART, OR IF YOU CHANGE THE NATURE OF
YOUR BUSINESS ENTITY (e.g. FROM A PARTNERSHIP TO A CORPORATION, FROM A CORPORATION TO A
PROPRIETORSHIP, ETC.) IT IS REQUIRED THAT YOU COMPLETE THIS FORM.
LISTED BELOW ARE FACTORS USED TO DETERMINE IF A SUCCESSION OCCURRED, FOR EXAMPLE:
1)
THE PERCENTAGE OF THE EXISTING BUSINESS ENTITY THAT WAS ACQUIRED BY YOU.
2)
THE PERCENTAGE OF THE BUSINESS ASSETS OF THE PREVIOUS OWNER ACQUIRED BY YOU. ASSETS ARE
DEFINED AS: INVENTORY, REAL PROPERTY, MACHINERY, ACCOUNTS RECEIVABLE, GOODWILL, ETC.
3)
DETERMINATION OF SUCCESSION IS ALSO BASED UPON THE AMOUNT OF TIME THAT HAS ELAPSED SINCE THE
PREVIOUS OWNERS CEASED EMPLOYING WORKERS IN FLORIDA AND THE NEW OWNERS BEGAN EMPLOYING
WORKERS.
1. PREVIOUS OWNER INFORMATION:
Legal Name
Trade Name (D/B/A)
Address
Florida Account #
FED I.D. #
Telephone #
Was the business being operated at the time of acquisition?
Yes
No
If No, date closed:
What is the principal product or services of the business?
2. CURRENT OWNER NAME:
Legal Name
Trade Name (D/B/A)
Address
Florida Account #
FED I.D. #
Telephone #
What is the principal product or services of the business?
3. DATE OF ACQUISTION
_________
Did you acquire all the business?
Yes_______
No _______
Unknown ______
If a rate transfer is desired and you have acquired 100 % of the business, item 5 must be completed. If you have acquired less than
100% of a business that is an identifiable and segregable portion of the business, and you desire a rate transfer, item 6 must be
completed.