Form Lb-0483 - Application For Transfer Of Experience Rating Record - 2008

ADVERTISEMENT

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
EX
EMPLOYER SERVICES (STATUS/RATES)
220 FRENCH LANDING DRIVE
NASHVILLE TENNESSEE 37243
(615)741-2486
FAX (615)741-7214
APPLICATION FOR TRANSFER OF EXPERIENCE RATING RECORD
UNLESS YOU ARE SUBJECT TO A MANDATORY TRANSFER OF EXPERIENCE AS PROVIDED FOR BY SECTION 50-7-403(b)(2)(C) OF
THE TENNESSEE EMPLOYMENT SECURITY LAW (SEE BACK OF FORM), THIS TRANSFER IS VOLUNTARY ON THE PART OF BOTH
PREDECESSOR AND SUCCESSOR.
(ALL INFORMATION MUST BE PROVIDED.)
1. NAME OF PREDECESSOR/
TRANSFEROR EMPLOYER _________________________________________________________________________________
ADDRESS _______________________________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
TENNESSEE ACCOUNT NUMBER ______________________
FEDERAL EMPLOYER ID NUMBER ____________________
2. EFFECTIVE DATE OF TRANSFER _____/_____/_____
3. TYPE OF TRANSFER
TOTAL
PARTIAL
4. IF PARTIAL TRANSFER,
PERCENT OF BUSINESS TRANSFERRED ____________________ %
PERCENT OF BUSINESS RETAINED BY PREDECESSOR ____________________ %
5. NAME OF SUCCESSOR/
TRANSFEREE EMPLOYER __________________________________________________________________________________
ADDRESS ________________________________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
TENNESSEE ACCOUNT NUMBER _______________________
FEDERAL EMPLOYER ID NUMBER ____________________
We, the predecessor and successor employers, do hereby jointly certify that the information provided herein is true and correct to the
best of our knowledge and belief. Furthermore, we hereby agree that premiums credited and both past and future benefits chargeable
to the account of the predecessor shall be divided between the predecessor and successor by a transfer percentage determined in accordance
with Section 50-7-403(b)(2)(A) of the Tennessee Employment Security Law. This application is a binding agreement and is irrevocable
once it has been properly executed, signed by both the predecessor and successor entities and approved by the Tennessee Department of
Labor and Workforce Development.
NOTE: This form must be signed by a corporate officer, authorized limited liability company member, partner, or proprietor of both the
predecessor and successor and be filed with the Department of Labor and Workforce Development during the calendar quarter in which
the acquisition occurs or during the calendar quarter immediately following such quarter as set out in Section 50-7-403(b)(2)(A) of the
Tennessee Employment Security Law.
6. PREDECESSOR/TRANSFEROR EMPLOYER
7. SUCCESSOR/TRANSFEREE EMPLOYER
SIGNED ________________________________________________
SIGNED _______________________________________________
PRINTED NAME _________________________________________
PRINTED NAME ________________________________________
TITLE __________________________________________________
TITLE _________________________________________________
DATE _____/_____/_____ PHONE: _________________________
DATE _____/_____/_____ PHONE ________________________
NOTARY REQUIRED
NOTARY REQUIRED
STATE OF ____________________ COUNTY OF _______________
STATE OF _________________ COUNTY OF ________________
___________________________ PERSONALLY APPEARED
__________________________ PERSONALLY APPEARED
BEFORE ME ON THE THE ____ DAY OF _______________, 20 ___
BEFORE ME ON THE ____ DAY OF _______________, 20 ___
WHO MAKES OATH THAT S/HE EXECUTED THE FOREGOING
WHO MAKES OATH THAT S/HE EXECUTED THE FOREGOING
INSTRUMENT.
INSTRUMENT.
NOTARY SIGNATURE AND SEAL
NOTARY SIGNATURE AND SEAL
MY COMMISSION EXPIRES _____________________________
MY COMMISSION EXPIRES _____________________________
LB-0483 (Rev. 1/08)
RDA 2271

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go