Successor'S Application For Partial Transfer Of Predecessors Experience History printable pdf download

NEW MEXICO DEPARTMENT OF WORKFORCE SOLUTIONS

P. O. Box 2281, Albuquerque, NM 87103

SUCCESSOR’S APPLICATION FOR PARTIAL TRANSFER OF PREDECESSOR’S EXPERIENCE HISTORY

SECTION A-Successor

1. Predecessor Account No.__________________

2. Successor Account No._______________________

Name__________________________________

Name_____________________________________

DBA__________________________________

DBA______________________________________

Address________________________________

Address___________________________________

__________________________________

___________________________________

3. Specify the type of business transfer transaction by which the predecessor conveyed the enterprises(s) to the

successor (Bill of sale, purchase contract, lease agreement, court order etc.)

4. Date you acquired this business:____________________

5. Date the successor first paid wages:_________________

6. How many employees did the successor have on the date he acquired the business?__________________

7. How many enterprises are/were being operated by the predecessor?_______________________

8. How many enterprises did you acquire from the predecessor?__________(list locations below)

___________________________________________________________________________

SECTION B-Successor’s Certificate (completed by successor)

I________________________________, certify that I am authorized to create an indebtedness against the

Foregoing successor; that I have read Form ESU-18A, General information and Instructions, which accompanied

this form; that the information contained in this form is true and correct; and I assume personal liability for any

contribution (tax) interest, and penalty which may later be determined by the Department to have been owing by the

predecessor.

Signed:__________________________________Title:________________________________Date:________

SECTION C-Predecessor’s Endorsement ( completed by predecessor)

I certify that the enterprise named in Section A #2 of the foregoing application was operated by me as a separate and

distinct employing enterprise throughout the entire period of the contribution liability, applicable to the enterprise,

and I have maintained and preserved payroll records which together with records of contribution liability and benefit

chargeability, can be separated from the enterprises which I have retained. I further certify that the enterprise being

transferred first became an employing unit (liable to me) as of____________(indicate the date of inception-the date

you became liable for that business).

If more than one enterprises is being transferred, please list the inception date of each:

Name of Enterprise_____________________

Date of Inception_______________________

Name of Enterprise_____________________

Date of Inception_______________________

I_______________________, hereby consent to transferring the part of experience history applicable to the

Transferred enterprise.

Signed:__________________________________Title:________________________________Date:________

ES-963A (Rev 2/07)

Successor'S Application For Partial Transfer Of Predecessors Experience History

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