Department of Workforce Development
Report of Business Transfer
Division of Unemployment Insurance
(Sale, Acquisition, or Reorganization)
PO Box 7942
Section 108.16(8) Wisconsin Statutes
Madison, WI 53707
Telephone: (608) 261-6700
Fax: (608) 267-1400
Personal Information you provide may be used for secondary
purposes [Privacy Law s. 15.04(1)(m), Wisconsin Statutes]. Provision
of your social security number (SSN) is voluntary; not providing it
could result in an information processing delay.
1. Former Owner/Operator
Telephone Number
Employer Legal Name
Unemployment Insurance Account Number
Trade Name
Federal ID Number
Form of Ownership (Check one)
Individual
Partnership
Corporation
Limited Partnership
Current Mailing Address (Street or PO Box, City, State, Zip Code)
Limited Liability Co.
LLC Electing to be Treated as a Corporation
Other:
Physical Location of Transferred Business
Ownership
Name(s) of Partner(s), Member(s), Stockholder(s)
SSN
Continue on additional page if necessary
Percentage
2. New Owner/Operator
Employer Legal Name
Unemployment Insurance Account Number
Telephone Number
Trade Name
Federal ID Number
Form of Ownership (Check one)
Individual
Partnership
Corporation
Limited Partnership
Current Mailing Address (Street or PO Box, City, State, Zip Code)
State of Incorporation
Limited Liability Co.
State of Registration
LLC Electing to be Treated as a Corporation
State of Registration
Other:
Name(s) of Partner(s), Member(s), Stockholder(s)
Ownership
SSN
Continue on additional page if necessary
Percentage
3. Relationship Between Parties in 1 and 2 Above
Are the new owner/operator(s) the same or related to the former owner/operator(s)? For example, married, parent/child, common
partners, stockholders, officers or parent business and subsidiary.
If yes, identify the relationship(s)
Yes
No
4. Effective Dates
Date first operated by
Date transfer
Date last operated by
____/____/____
____/____/____
____/____/____
became effective
new owner/operator
former owner/operator
5. Options for New Owner/Operator
You may have an option to acquire the Unemployment Insurance experience of the former owner.
You must
If the date of
An applicaton to acquire this experience must be filed by the appropriate date. See chart at right.
apply by:
change is:
Check one of the following statements
Jan. 1 to March 31
July 31
April 1 to June 30
Oct. 31
This is my application to acquire the account experience of the former owner
July 1 to Sept. 30
Jan. 31
I do not want to acquire the account experience
Oct. 1 to Dec. 31
April 30
I have not yet received the former owner's account information
UCT-115-E (R. 06/08/2016)