Fillable Form Sfn 41216 - Report To Determine Liability (Page 4 of 4) in pdf

Complete Schedule B only if you answered “yes” to question 11 on

REPORT TO DETERMINE LIABILITY

form SFN 41216, Report to Determine Liability

SCHEDULE B - SUCCESSORSHIP QUESTIONNAIRE

Successorship Reporting Requirement. If you acquired all or part of the organization, business, trade, or assets of another employer and will continue

essentially the same business activity, you must provide the following information. If you made multiple acquisitions, you must file a separate Schedule B for

each acquisition. Submit the completed Schedule B(s) along with Form SFN 41216, Report to Determine Liability, to Job Service North Dakota.

PART 1: CURRENT/NEW OWNER INFORMATION

Name

UI Account Number

Federal Employer Identification Number

PART 2: FORMER OWNER INFORMATION

Former Owner's Name (required)

Former Owner's UI Number or FEIN, if known

Corporate Name or DBA

Area Code and Telephone Number

Current Street Address (not a P.O. Box)

City

State

ZIP Code

PART 3: ACQUISITION INFORMATION

Percent Acquired Date Acquired

1. Did you acquire all, part or none of the former owner's assets?

All

Part

None

Percent Acquired Date Acquired

2. Did you acquire all, part or none of the former owner's workforce?

All

Part

None

Percent Acquired Date Acquired

3. Did you acquire all, part or none of the former owner's North

All

Part

None

Dakota trade (customers/accounts)?

Percent Acquired Date Acquired

4. Did you acquire all, part or none of the former owner's North

All

Part

None

Dakota business (products/services)?

Date (MM, DD, YYYY)

5. Was the North Dakota business being operated at the time of the

Yes

acquisition? If no, enter the date it was closed by the former owner.

6. Are you continuing the North Dakota business you acquired?

Yes

7. Is your North Dakota business substantially owned or controlled in

any way by the same interests that owned or controlled the former

Yes

business?

8. Will the previous business/account continue in business in North

Yes

Don't Know

Dakota?

9. If eligible, do you wish to continue the experience rating established

Yes

by the acquired/previous business?

If you do and are assigned your predecessor's tax rate, your new account will also be chargeable for any benefits payable to your

predecessor's workers.

If you do not answer this question and it is determined that you are a liable employer, you will receive the rate normally assigned to new employers; it will

not include the predecessor's history.

NDCC 52-04-08.2 provides for penalties in cases where the acquisition of a business is solely or primarily for the

purpose of obtaining a lower unemployment insurance tax rate. Criminal and/or civil penalties apply.

Name of Owner/Officer

Title

Telephone Number

Date

I certify the information on SFN 41216, Schedule B, is true and accurate.

Go to the bottom of page 3 to submit the form.

Notice: Wage and other confidential information collected from employers as part of the unemployment insurance process may be

requested and utilized for other governmental purposes, including, but not limited to, verification of eligibility under other government

programs as required by law.