Form Ucs-1s - Report To Determine Succession And Application For Transfer Of Experience Rating Records

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UCS-1S
Report to Determine Succession and Application for Transfer
R. 12/01
of Experience Rating Records
If you purchase or lease an existing business, in whole or in part, or if you change the nature of your business
entity (e.g. from a partnership to a corporation, from a corporation to a proprietorship, etc.) it is required that you
complete this form.
Listed below are factors used to determine if a succession occurred, for example:
1)
The percentage of the existing business entity that was acquired by you.
2)
The percentage of the business assets of the previous owner acquired by you. Assets are defined as: inventory, real property,
machinery, accounts receivable, goodwill, etc.
3)
Determination of succession is also based upon the amount of time that has elapsed since the previous owners ceased employing
workers in Florida and the new owners began employing workers.
1. Previous owner information:
Legal Name _______________________________________________________________________________________________
Trade Name (D/B/A) ________________________________________________________________________________________
Address __________________________________________________________________________________________________
________________________________________________________________________________________________________
UT Account # ____________________________ FED I.D. # ______________________ Telephone # _______________________
Was the business being operated at the time of acquisition? ____________ Yes _____________ No
If No, date closed: ___________________________________________________________________________________
What is the principal product or services of the business? ___________________________________________________________
2. Current owner name:
Legal Name _______________________________________________________________________________________________
Trade Name (D/B/A) ________________________________________________________________________________________
Address __________________________________________________________________________________________________
________________________________________________________________________________________________________
UT Account # ____________________________ FED I.D. # ______________________ Telephone # _______________________
What is the principal product or services of the business? ___________________________________________________________
3. Date of acquisition _____________ Did you acquire all the business? Yes ____ No ____ Unknown _______
Mail completed form to:
Florida Department of Revenue
PO Box 6510
Tallahassee, FL 32314-6510

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