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Application For Voluntary Successorship: Transfer Of Clearly Segregable And Identifiable Portion Form - Ohio Department Of Job And Family Services

OHIO DEPARTMENT OF JOB AND FAMILY SERVICES

P.O. BOX 182404

Columbus, Ohio 43218-2404

(614) 466-2319

FOR 0027

APPLICATION FOR VOLUNTARY SUCCESSORSHIP: TRANSFER OF CLEARLY SEGREGABLE

AND IDENTIFIABLE PORTION

To apply for a voluntary successorship online, please visit our website at

anytime of the day or night. If

you prefer, you may submit your information by completing this form and we will notify you in writing of the outcome. When completing

this form, please print using block capital letters in black ink. For example:

1 a. Transferee's Employer Name

1 b. Transferee's Employer Account Number

1 c. Transferee's Telephone Number

Note: If you do not have an account number, you must submit a

Report to Determine Liability (JFS 20100) with this application.

1 d. If you have not already submitted a Transfer of Business form (JFS 20101), you must submit one with this application.

2 a. Transferor's Employer Name

2 b. Transferor's Employer Account Number

2 c. Transferor's Telephone Number

2 d. If you have not already submitted a Disposition of Business form (JFS 20110), you must submit one with this application.

3. Trade name and a detailed description of the portion or division of the business transferred.

JFS 20119 (9/2010)

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Application For Voluntary Successorship: Transfer Of Clearly Segregable And Identifiable Portion Form - Ohio Department Of Job And Family Services