Application For Voluntary Successorship: Transfer Of Clearly Segregable And Identifiable Portion Form - Ohio Department Of Job And Family Services Page 2
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5T
4. Physcial address of the transferred portion or division.
Address Line 1 - Please do not enter a PO Box.
Address Line 2 - Please do not enter a PO Box.
City
State
ZIP
Country
-
Province - International addresses only
Postal Delivery Code – International addresses only
5. What was the date of first employment for the portion or the division while it was part of the predecessor?
/
/
6. What was the date of transfer?
/
/
7.
Provide gross and taxable payroll totals attributable to the transferred portion for the four completed calendar quarters immediately
preceeding the quarter in which the transfer occurred.
Wages for individuals covered under the Ohio Unemployment Compensation law attributable to the
transferred portion
Quarter
Gross
Taxable
$
,
,
.
,
,
.
$
Year
Quarter
Gross
Taxable
,
,
.
,
,
.
$
$
Year
Quarter
Gross
Taxable
.
$
,
,
,
,
$
.
Year
Quarter
Gross
Taxable
.
$
,
,
.
,
,
$
Year
Page 2 of 6
JFS 20119 (9/2010)
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