Looking for a New Mexico Department Of Labor Forms And Templates? Download it for free!

Form Es-963a - Successor'S Application For Partial Transfer Of Predecessor'S Experience History

ES-963A (Rev. 5/98)

Page 1

NEW MEXICO DEPARTMENT OF LABOR

P O BOX 2281

ALBUQUERQUE, NM 87103

SUCCESSOR'S APPLICATION FOR PARTIAL TRANSFER OF PREDECESSOR'S EXPERIENCE HISTORY

PREDECESSOR ACCT NUMBER

SUCCESSOR ACCT NUMBER

NAME

DBA

ADDRESS

Specify the type of business transfer transaction by which the predecessor conveyed the

enterprise(s) to the successor (Bill-of-Sale, purchase contract, lease agreement, court

order, etc.):

Specify the effective date of the transaction:

Specify the date upon which the successor became responsible for hiring

and

discharging employees:

(If this date is different

from that of the transaction, explain the reason for the difference):

How many employees did the successor have in New Mexico on the effective date

acquiring the enterprise(s)?

Has the predecessor submitted to the Department all wage reports, contributions, (tax),

interest and penalties due from him?

(Yes or No)

----------------------------------------------------------------------------------------------

SUCCESSOR'S CERTIFICATE

, certify that I am authorized to create an indebtedness

against the foregoing named successor; that I have read Form ESU-18, General Information and

Instructions, which accompanied this form; that the information contained in this form is true

and correct; and I assume personal liability for any contribution (tax), interest, and penalty

which may later be determined by the Department to have been owing by the predecessor.

Signed

Date

Title

----------------------------------------------------------------------------------------------

PREDECESSOR'S ENDORSEMENT

I certify that the enterprise(s) named at 2 of the foregoing application was/were

operated

by me as separate and distinct employing enterprise(s) throughout the entire period of my

contribution liability applicable to each enterprise, and I have maintained and preserved

payroll

records

which,

together

with

records

contribution

liability

and

benefit

chargeability, can be separated from the enterprises which I have retained.

I further certify

that the inception date(s) of the enterprise(s) named at 2 of the foregoing is/are as follows:

Name of Enterprise

Inception Date

Name of Enterprise

Inception Date

(attached separate sheet if necessary)

I consent to transferring that part of the experience history which is applicable to the

transferred enterprise(s).

Date

Signed

Title

(submit in triplicate)

001-1046

Form Es-963a - Successor'S Application For Partial Transfer Of Predecessor'S Experience History

Related Articles

Related forms

Related Categories