Form Application And Agreement For Partial Transfer Of Experience Rating Record - Louisiana Department Of Labor
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1
2APPLICATION AND AGREEMENT FOR PARTIAL TRANSFER OF EXPERIENCE RATING RECORD
Complete this form only if your account acquired a portion of an existing business. Item # 15(a) on your Status Report should be answered
“yes.”
This application is due
180 days
from the date of the partial acquisition and furnishes information needed to secure a partial transfer of experience
rating records. If approved, the partial successor will receive the indicated taxable payroll for the transferred employees shown below. These
amounts will be deducted from the taxable payroll of the partial predecessor for the same periods. Also, the successor will receive the indicated
percentage of the predecessor’s reserve, benefit charges, and contributions for the fiscal year ending immediately prior to the segregation year, and
for the interim quarters up to the segregation date. Likewise, these amounts will be deducted from the predecessor’s experience rating records for
the same period.
1. Successor (Buyer)
2. Predecessor (Seller)
Account No. _______________________________
Account No. ________________________________
Business Name______________________________
Business Name_______________________________
Address ___________________________________
Address ___________________________________
City, State, Zip ______________________________
City, State, Zip ______________________________
3. Date “identifiable or segregable portion” of organization, trade, or business transferred: Month/Day/Year ______________________________.
4. Law requires that employers involved advise the Agency of the percentage of transfer. This percentage must be agreed upon by both employers.
One method of calculating the percentage of transfer is as follows. To calculate the percentage of experience rating records to be transferred
list below the amount of
taxable payroll
(not total payroll) by
fiscal year
(not calendar year) related to the transferred portion of the business.
It should be listed for the three completed fiscal years ending immediately prior to the segregation year. For example, if segregation occurred
anytime in 2000, the taxable payrolls for fiscal years ending 6/99, 6/98 and 6/97 should be provided. If both employers agree on a percentage
without actually dividing the transferred taxable payroll by the predecessor's taxable payroll, only complete the percentage blank below. That
percentage will be used to transfer the predecessor's experience rating records to the successor's account.
Taxable Payroll of Employees of Transferred Portion
Taxable Payroll of all Employees of the Predecessor
Successor No. __________________
Predecessor No. __________________
F/Y ending 6/30/ ____
$ _____________________
F/Y ending 6/30/ ____
$ _____________________
F/Y ending 6/30/ ____
$ _____________________
F/Y ending 6/30/ ____
$ _____________________
F/Y ending 6/30/ ____
$ _____________________
F/Y ending 6/30/ ____
$ _____________________
0.00
0.00
Total all quarters
$ _____________________
Total all quarters
$ _____________________
Transferred Portion Taxable Payroll Total
-------------------------------------------------
= Percentage of Data Transferred______________%
Predecessor’s Taxable Payroll Total
5. This application must be signed by the respective employers, duly elected officials, or their authorized representatives.
6. We, the predecessor and successor employers, mutually consent to and hereby request the transfer of the “identifiable or segregable portion”
of the predecessor’s experience rating record, related to the transferred portion of the business, in accordance with Employment Security Law.
Furthermore, we do hereby jointly certify that the information provided herein and on the reverse is true to the best of our knowledge and belief.
SUCCESSOR
PREDECESSOR
______________________________________
Signature
_______________________________________
______________________________________
Title
_______________________________________
______________________________________
Date Signed _______________________________________
(________) ____________________________
Telephone # (________) _____________________________
Rev. (1/03)
Page
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