Form 309-6701 - Contractor Registration Application/renewal Form/form 60-0126 - Report To Determine Liability Page 8

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Report to Determine Liability
60-0126 (03-12)
Complete the section below if you have acquired, purchased, leased or assumed all or part of an existing business operating in Iowa.
Change of Ownership
Legal date of transfer
Explain circumstances of the change
Yes
No
Did you acquire substantially all of the Iowa business?
If Yes, and you already have an account, do you want the tax rate recomputed for the balance of the
Yes
No
year in which the transaction occurred?
Reset
If No, answer the next question.
If you did not acquire substantially all of the Iowa business, was the part acquired a clearly separable
Yes
No
and identifiable portion?
Yes
No
If Yes, do you wish a partial transfer of experience from that business?
Note: A partial transfer of experience must be requested within 90 days of the transfer of the business.
Enter the following information about the previous business:
UI Account #
Legal Business Name or Individual Name
DBA or Trade Name
Address 1:
Address 2:
City:
State:
Zip+4/Postal:
Contact Name:
Contact Title:
Phone:
Ext:
Email:
Financial Institution and Accountant Information
Enter the contact information for your financial institution below:
Institution:
Address:
City:
State:
Phone:
Zip+4/Postal:
Ext:
If your business uses an outside accounting firm, enter their contact information below:
Firm Name:
Contact Name:
Title:
Phone:
Ext:
Alternate Phone:
Fax:
Ext:
Email:
Address:
City:
State:
Zip/Postal:
Country:
I declare that the information provided is true and correct to best of my knowledge.
Signature (Authorized Representative)
Print Name
Title
Phone
Ext
Date
Return this form to:
Iowa Workforce Development
Unemployment Insurance Tax Bureau
1000 E Grand Ave
Des Moines IA 50319-0209
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