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Form 2837 - Report To Determine Status - Indiana Department Of Workforce Development Page 2

(continued)

REPORT TO DETERMINE STATUS

(Account Number)

If you acquired, purchased or continued all or any part of an existing Indiana business, you must complete "Section A"

below. Reference Indiana Code 22-4-7-2, Indiana Code 22-4-10-6.

NOTE:

If you acquired only a portion of an existing Indiana business, upon application and agreement by both the

disposer and acquirer, you (the acquirer) may be entitled to use the same rate as the disposer in the year of

acquistion. Reference Indiana Code 22-4-17-2(b), Indiana Code 22-4-10-6(b).

SECTION A

If you have questions whether or not this section applies to you, please call (317) 232-7436.

(check one)

Nature of acquisition or change of entity:

Purchase of COMPLETE organization

Lease of complete organization

Partnership change or reorganization

Purchase of a PORTION of organization

(50% or more partners changed)

Corporate change or reorganization

Spin-Off of a Subsidiary

Death of owner or partner

Change in Federal ID

Bankruptcy or other proceedings

Other (please explain in Remarks section below)

(mm-dd-yy) ___ ___ ___

Date you purchased, reorganized, incorporated or otherwise took control of the Indiana business:

__ __ __ __ __ __ ( ___ )

1. Predecessor/disposer Indiana SUTA Number:

__ __ - __ __ __ __ __ __ __

2. Predecessor/disposer Federal ID Number:

3. Predecessor/disposer Legal Name

4. Trade Name (or d/b/a)

5. Mailing Address

City

State

ZIP Code (+ 4 + 2 + 1)

__ __ __ __ __ - __ __ __ __ - __ __ - __

Indiana County

6. SIGN AND DATE THE FRONT OF THIS FORM WHERE INDICATED.

REMARKS:

Form 2837 - Report To Determine Status - Indiana Department Of Workforce Development Page 2