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
R. 02/10
for Transfer of Experience Rating Records
Rule 60BB-2.037
Florida Administrative Code
I
f 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.) you are required to complete this form.
Listed below are factors used to determine if a succession occurred, for example:
• The percentage of the existing business entity that was
• Determination of succession is also based upon the
acquired by you.
amount of time that has elapsed since the previous owners
ceased employing workers in Florida and the new owners
• To be considered an “identifiable and separate” portion of
began employing workers.
a business, the portion must be a distinct entity that could
operate independently from the remainder of the business.
1.
Previous owner information:
Legal name: _________________________________________________________________________________________________
Trade name (D/B/A): __________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
UT Account No.: ____________________________ FEIN: ______________________ Telephone: ___________________________
Was the business being operated at the time of acquisition?
Yes
No If no, date closed: ________________________
What is the principal product or service of the business? __________________________________________________________
2.
Current owner name:
Legal name: _________________________________________________________________________________________________
Trade name (D/B/A): __________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
UT Account No.: ____________________________ FEIN: ______________________ Telephone: ___________________________
What is the principal product or services of the business? _________________________________________________________
Was there any common ownership, management, or control between the two entities at the time the
purchase/change occurred? Yes
No
3.
What is the nature of the acquisition or change of business entity?
a) Purchase of business:
entire or
part
b) Did the former owner operate more than one location in Florida?
Yes
No
c) Lease of business:
entire or
part
d) Acquire by franchise:
Yes
No If “Yes”, did you acquire from:
franchisee or
franchiser
e) Change in type of business: From:
Sole Proprietor
Partnership
Corporation
LLC
To:
Sole Proprietor
Partnership
Corporation
LLC
f) Partnership reorganization:
(Admission or withdrawal of one or more partners)
g) Corporate change:
Merger or consolidation
Reorganization
Issuance of new corporate charter
h) Legal or insolvency proceedings:
Foreclosure
Bankruptcy
Receivership: Ordered by the court
Yes
No
i) Death of:
Owner
Partner

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