Application For Partial Transfer Of Experience - Illinois Department Of Employment Security - 2010 Page 2
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2CERTIFICATION - WAIVER - AGREEMENT
The undersigned TRANSFEREE and TRANSFEROR herby certify that the portion acquired by
TRANSFEREE was a distinct severable portion of the employing enterprises of the Predecessor; that the
information contained in this Application and in any sheets attached hereto is true and correct to the best of
their knowledge and belief; and that they execute these documents for the purpose of transferring from the
TRANSFEROR to the TRANSFEREE that portion of the experience rating record which is attributable to the
portion of the employing enterprises acquired by the TRANSFEREE.
TRANSFEROR hereby waives his rights to a contribution rate based on the experience rating record
attributable to the portion of the employing enterprises acquired by the TRANSFEREE.
If the Predecessor is delinquent in the payment of contributions for any quarter involved in the determination
of a contribution rate affected by this Application, TRANSFEREE and TRANSFEROR hereby agree that the
Director shall allocate to the TRANSFEREE an amount of Wages on Which Contributions Were Paid in the
same proportion as the taxable wages attributable to TRANSFEREE bear to the Predecessor’s total taxable
wages for the same quarter.
TRANSFEREE and TRANSFEROR hereby agree to furnish to the Department of Employment Security
any additional allocation of TAXABLE WAGES AND BENEFIT CHARGES which the Director of Employment
Security may require. Both parties hereby agree that such additional allocation, and any allocation made by
the Director on the basis of information contained in this Application shall be treated as part of this Application
for Partial Transfer of Experience.
TRANSFEREE
TRANSFEROR
]
Business Name ______________________
Business Name ________________________
Signed By __________________________
Signed By ____________________________
]
Official Title _________________________
Official Title ___________________________
Date Signed ________________________
Date Signed ___________________________
This application must be signed by owner, partner, or officer of each employing unit. If signed by any
other person, a power of attorney giving such person individual authority to sign it must be on file..
YOU ARE CAUTIONED THAT ONCE AN APPLICATION FOR PARTIAL TRANSFER IS APPROVED BY
THE DIRECTOR OF EMPLOYMENT SECURITY, IT BECOMES FINAL UPON THE PARTIES THERETO
AND CANNOT SUBSEQUENTLY BE WITHDRAWN BY THEM.
Please PRINT signatures from above:
X ___________________________
X _________________________
Rev. 05-10
ER-65
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Parent category: Financial