Form K-Cns 010 - Employer Status Report - Kansas Department Of Labor - 2017 Page 3

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Kansas Department of Labor

Page 3 of 5

Employer Status Report

K-CNS 010 (Rev. 5-17)

18. Did you acquire/purchase all or part of an existing business?

c YES

c NO

18a. If YES, the date acquired (mm/dd/yyyy): ____________________

c All

c Part

______ % acquired

Did you acquire substantially all of the assets?

c YES

c NO

Did you acquire substantially all of the employing enterprise, organization, trade or business?

c YES

c NO

Termination date of prior owner (mm/dd/yyyy): ____________________

18b. Has the previous owner continued business in Kansas?

c YES

c NO

If YES, explain:

____________________________________________________________________________________________

18c. Do you want the prior owner’s experience rating factors? c YES

c NO

Transfer of rating factors is:

c Mandatory

c Elective

18d. Name of prior owner: __________________________________

Prior owner’s Kansas employer serial number: _______________

18e. Prior business or trade name: _____________________________________ Current phone: ___________ ________

18f. Prior owner’s current address: Street ______________________________________________________________

City: _______________________________________________ State: _________ ZIP: ______________________

K.S.A. 44-710a(b)(2) allows a successor, defined in K.S.A. 44-703(h)(4) and K.S.A. 44-703(dd), the choice to acquire the experience rating factors of the

predecessor employer. The request for transfer must be made in writing within 120 days of the acquisition. The experience rating factors are all of the

unemployment taxes paid, annual payrolls and benefit charges of the predecessor employer. These factors are used to compute your unemployment tax rate

for subsequent years. Alternately, successor employers may elect to be assigned their industry tax rate.

19. For the last three years, list any multiple business locations you have operated in KANSAS.

c No multiple locations

Trade Name and Address

Date Opened

Date Closed No. Employees

Business Activity

20. Are you subject to Federal Unemployment Tax Act (FUTA)? Current year: c YES

c NO

Prior year: c YES c NO

21. If no liability is indicated, do you wish to elect coverage?

YES, beginning January 1 of the current year, or at the commencement of employment of the current year, and