Form De 4453 - Application For Transfer Of Reserve Account Page 2
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213. Number of workers employed by seller just before sale
14. Number of workers employed by you
15. Are you a labor contractor, employment agency or other provider of employment services?
Yes
No
If yes, explain operation
16. You took over from the former owner:
(a) ALL the business:
(If you checked this box, go directly to Section III)
(b) PART of the business:
(If you checked this box, complete Sections II and III)
II.
1. That portion of the business which you acquired was started by its original owner on (date)
2. The taxable wages, for the portion of the former owner’s business which you acquired, were as follows:
(USE ONLY WAGES UP TO THE $7,000 ANNUAL LIMIT FOR EACH EMPLOYEE FOR CALENDAR YEARS LISTED
BELOW)
For entire calendar years of:
2000 $
2001 $
2002 $
- BY QUARTERS -
JAN. 1 TO MARCH 31
APRIL 1 TO JUNE 30
JULY 1 TO SEPT. 30
OCT. 1 TO DEC. 31
2003 $
$
$
$
2004 $
$
$
$
If you cannot get exact figures, you may give us your estimate. We will then send your figures to the former owner to
approve or correct.
Did you estimate these figures?
Yes
No
Did the former owner approve these figures?
Yes
No
III. Please list the name and phone number of the person we can contact for further information, if needed.
Print Name:
Phone: (
)
SIGN AND DATE: I/we hereby make application for transfer of reserve account and declare that the above information is
correct to the best of our knowledge and belief.
Signature:
Phone: (
)
Title:
Date:
DE 4453 Rev. 60 (3-04) (INTERNET)
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