Application For Partial Transfer Of Experience - Illinois Department Of Employment Security - 2010

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State of Illinois
33 South State Street
Department of Employment Security
Chicago, Illinois 60603-2802
Application for Partial Transfer of Experience
TRANSFEREE (SUCCESSOR)
TRANSFEROR (PREDECESSOR)
We, The undersigned employing units, hereby jointly make application to the Director of Employment Security under the
provisions of Section 1507B of the Illinois Unemployment Insurance Act for the transfer of that part of the experience rating
record of the TRANSFEROR which is attributable to the portion of the employing enterprises acquired by the TRANSFEREE.
We hereby submit the following information in support of our application and as a basis for the Director’s transfer of such
experience rating record:
1.
Date on which TRANSFEREE acquired a portion of his PREDECESSOR___________________________________
2.
Name and address of PREDECESSOR_______________________________________________________________
(Name)
________________________________________________________________________________________________
(Trade Name)
(Address)
3.
Beginning date of the quarter for which PREDECESSOR first had wages subject to contribution under the Illinois
Unemployment Insurance Act in the portion acquired by TRANSFEREE ___________________________________
4.
In the calendar year during which Predecessor disposed of a portion of his employing enterprises to Transferee, and in
each of the four calendar years immediately preceding that year, did PREDECESSOR have wages subject to contribution
under the Illinois Act in the portion acquired by the TRANSFEREE?
 NO If no, indicate each calendar year within that period in which PREDECESSOR did NOT have such wages
YES
in said portion:________________________________________________ ___________________________________
5.
In the calendar year during which Predecessor disposed of a portion of his employing enterprises to Transferee, and in
each of the four calendar years immediately preceding that year, did PREDECESSOR have wages subject to contribution
under the Illinois Act other than the wages attributable to the portion acquired by TRANSFEREE and to portions acquired
 NO
by other Transferees, if any?
If no, indicate each calendar year within that period in which
YES
PREDECESSOR did not have such wages:
__________________________________________________________
__________________
________
6. On the date given in item 1, was TRANSFEREE owned or controlled by the same interests which owned or
? 
 NO If yes, attach sheet giving complete
controlled his PREDECESSOR immediately prior to that date
YES
details regarding all elements of such common ownership and control on that date and regarding subsequent changes, if
any.
(over)

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