Free lb0483NewAddress1.08.pmd - Tennessee

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT EMPLOYER SERVICES (STATUS/RATES) 220 FRENCH LANDING DRIVE NASHVILLE TENNESSEE 37243 (615)741-2486 FAX (615)741-7214

EX

APPLICATION FOR TRANSFER OF EXPERIENCE RATING RECORD
UNLESS YOU ARE SUBJECT TO A MANDATORY TRANSFER OF EXPERIENCE AS PROVIDED FOR BY SECTION 50-7-403(b)(2)(C) OF THE TENNESSEE EMPLOYMENT SECURITY LAW (SEE BACK OF FORM), THIS TRANSFER IS VOLUNTARY ON THE PART OF BOTH PREDECESSOR AND SUCCESSOR.
(ALL INFORMATION MUST BE PROVIDED.)

1. NAME OF PREDECESSOR/ TRANSFEROR EMPLOYER _________________________________________________________________________________ ADDRESS _______________________________________________________________________________________________ (Street) (City) (State) (Zip Code) TENNESSEE ACCOUNT NUMBER ______________________ 2. EFFECTIVE DATE OF TRANSFER _____/_____/_____ 4. IF PARTIAL TRANSFER, FEDERAL EMPLOYER ID NUMBER ____________________ 3. TYPE OF TRANSFER TOTAL PARTIAL

PERCENT OF BUSINESS TRANSFERRED ____________________ % PERCENT OF BUSINESS RETAINED BY PREDECESSOR ____________________ %

5. NAME OF SUCCESSOR/ TRANSFEREE EMPLOYER __________________________________________________________________________________ ADDRESS ________________________________________________________________________________________________ (Street) (City) (State) (Zip Code) TENNESSEE ACCOUNT NUMBER _______________________ FEDERAL EMPLOYER ID NUMBER ____________________

We, the predecessor and successor employers, do hereby jointly certify that the information provided herein is true and correct to the best of our knowledge and belief. Furthermore, we hereby agree that premiums credited and both past and future benefits chargeable to the account of the predecessor shall be divided between the predecessor and successor by a transfer percentage determined in accordance with Section 50-7-403(b)(2)(A) of the Tennessee Employment Security Law. This application is a binding agreement and is irrevocable once it has been properly executed, signed by both the predecessor and successor entities and approved by the Tennessee Department of Labor and Workforce Development. NOTE: This form must be signed by a corporate officer, authorized limited liability company member, partner, or proprietor of both the predecessor and successor and be filed with the Department of Labor and Workforce Development during the calendar quarter in which the acquisition occurs or during the calendar quarter immediately following such quarter as set out in Section 50-7-403(b)(2)(A) of the Tennessee Employment Security Law. 6. PREDECESSOR/TRANSFEROR EMPLOYER
SIGNED ________________________________________________ PRINTED NAME _________________________________________ TITLE __________________________________________________ DATE _____/_____/_____ PHONE: _________________________ NOTARY REQUIRED STATE OF ____________________ COUNTY OF _______________ ___________________________ PERSONALLY APPEARED BEFORE ME ON THE THE ____ DAY OF _______________, 20 ___ WHO MAKES OATH THAT S/HE EXECUTED THE FOREGOING INSTRUMENT.

7. SUCCESSOR/TRANSFEREE EMPLOYER
SIGNED _______________________________________________ PRINTED NAME ________________________________________ TITLE _________________________________________________ DATE _____/_____/_____ PHONE ________________________ NOTARY REQUIRED STATE OF _________________ COUNTY OF ________________ __________________________ PERSONALLY APPEARED BEFORE ME ON THE ____ DAY OF _______________, 20 ___ WHO MAKES OATH THAT S/HE EXECUTED THE FOREGOING INSTRUMENT.

NOTARY SIGNATURE AND SEAL MY COMMISSION EXPIRES _____________________________
LB-0483 (Rev. 1/08)

NOTARY SIGNATURE AND SEAL MY COMMISSION EXPIRES _____________________________
RDA 2271

IMPORTANT NOTICE

Tennessee Employment Security Law provides for the mandatory transfer of an employer's experience rating factors whenever there is any common ownership, management or control between the predecessor and successor employers. "50-7-403(b)(2)(C) Notwithstanding any other provision of law, the following shall apply regarding assignment of premium rates and transfers of benefit and premium experience of an employer's trade or business, or a portion thereof, to another employer if, at the time of the transfer, there is any common ownership, management or control of the two employers. In such cases the benefit and premium experience attributable to the transferred trade or business shall be transferred to the employer to whom such trade or business is so transferred. The reserve ratios and premium rates of both employers shall be recalculated and made effective immediately upon the date of the transfer of the trade or business." "50-7-403(b)(2)(C)(i) For purposes of this section the term "trade or business" shall include the employer's workforce." "50-7-403(b)(2)(C)(ii) "Common ownership, management or control" includes any individual who has at least a 10% ownership interest in or participates in the management or control of the predecessor's trade or business and who has a relative who has a 10% ownership interest in or participates in the management or control of the successor's trade or business. For purposes of this subdivision, "relative" means spouse, child, stepchild, adopted child, grandchild, son-in-law, daughter-in-law, parent, step-parent, parent-in-law, grandparent, brother, sister, half brother, half sister, step-brother, step-sister, brother-in-law, sister-in-law, aunt, uncle, nephew and niece."

LB-0483 (Rev. 1/08)

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