Free UCS-1S - Florida

UCS-1S R. 08/07 Page 1

Report to Determine Succession and Application for Transfer of Experience Rating Records
If you purchase or lease an existing business, in whole or in part, or if you change the nature of your business entity (e.g.,
from a partnership to a corporation, from a corporation to a proprietorship, etc.) you are required to complete this form. Listed below are factors used to determine if a succession occurred, for example: · The percentage of the existing business entity that was acquired by you. · To be considered an "identifiable and separate" portion of a business, the portion must be a distinct entity that could operate independently from the remainder of the business. 1. Previous owner information: Legal name: _________________________________________________________________________________________________ Trade name (D/B/A): __________________________________________________________________________________________ Address: ____________________________________________________________________________________________________ _____________________________________________________________________________________________________________ UT Account No.: ____________________________ FEIN: ______________________ Telephone: ___________________________ Was the business being operated at the time of acquisition? Yes No If no, date closed: ________________________ · Determination of succession is also based upon the amount of time that has elapsed since the previous owners ceased employing workers in Florida and the new owners began employing workers.

What is the principal product or service of the business? __________________________________________________________ 2. Current owner name: Legal name: _________________________________________________________________________________________________ Trade name (D/B/A): __________________________________________________________________________________________ Address: ____________________________________________________________________________________________________ _____________________________________________________________________________________________________________ UT Account No.: ____________________________ FEIN: ______________________ Telephone: ___________________________ What is the principal product or services of the business? _________________________________________________________ Was there any common ownership, management, or control between the two entities at the time the purchase/change occurred? Yes 3. No

What is the nature of the acquisition or change of business entity? a) Purchase of business: c) Lease of business: d) Acquire by franchise: entire or entire or Yes To: f) Partnership reorganization: g) Corporate change: h) Legal or insolvency proceedings: i) Death of: Owner Partner part Yes No franchisee or Corporation Corporation franchiser LLC LLC part No If "Yes", did you acquire from: Sole Proprietor Sole Proprietor Partnership Partnership

b) Did the former owner operate more than one location in Florida?

e) Change in type of business: From:

(Admission or withdrawal of one or more partners) Reorganization Bankruptcy Yes No Issuance of new Corporate Charter Foreclosure

Merger or Consolidation

Receivership: Ordered by the Court

UCS-1S R. 08/07 Page 2

4. Date of acquisition __________/__________/__________. Did you acquire all of the business? Yes (Complete number 5(a) OR number 5(c) below, not both.) No (Complete number 5(b) OR number 5(c) below, not both.)

5(a).

Total Succession (You have acquired 100% of the business and the predecessor has ceased payroll in Florida.) In consideration of the transfer, the successor will be responsible for any indebtedness that is past due with respect to wages paid by the predecessor prior to the date of succession. Any unemployment benefits paid to former employees of the predecessor will be charged to the successor employer and will be used in future tax rate calculations. The successor employer does hereby request a transfer of the employment records from the account of the predecessor employer. Upon receipt of a timely Form UCS-1S, the Department will compute your rate and notify you by mail. You will then have 20 days to withdraw the application if you do not want the rate. Successor signature: ___________________________________________________________ Date: _________________ Print name: _________________________________________ Title: ____________________________________________

5(b).

Partial Succession (You have acquired less than 100% of a business and the portion you acquired is an identifiable and separate portion of the business you acquired.) This portion of the form must be accompanied by the List of Employees to be Transferred (UCS-1SA) if you are transferring up to ten employees. If you are transferring more than ten employees, you must send a list of employees to the Department electronically. For information on how to access the online system, please call 800-482-8293. The successor employer is liable for benefit charges paid to transferred employees for any claim based on wages paid by the predecessor up to the date of succession. The successor employer does hereby request a transfer of the employment records from the predecessor employer. Upon receipt of a timely Form UCS-1S and Form UCS-1SA, the Department will compute your rate and notify you by mail. You will then have 20 days to withdraw the application if you do not want the rate. Successor signature: ___________________________________________________________ Date: _________________ Print name: _________________________________________ To be completed by the predecessor employer: Provide the date the employing unit being transferred first employed workers. This is not the acquisition date, but is the date the unit was first reported by the predecessor(s): _____________________________ The predecessor employer hereby agrees to furnish such employment records pertaining to employment in that portion of the business acquired by the successor employer and certifies that the form attached to the application represents only employment in the portion of the business during the periods covered by the forms. I understand that my future tax rate may be affected. Predecessor signature: __________________________________________________________ Date: _________________ Print name: _________________________________________ Title: ____________________________________________ Title: ____________________________________________

Select Only One
5(c).

Rejection of Transfer The successor employer does hereby refuse a transfer of the employment records from the account of the predecessor employer. Successor signature: ___________________________________________________________ Date: _________________ Print name: _________________________________________ Title: ____________________________________________

Mail completed form to: Account Management Florida Department of Revenue PO Box 6510 Tallahassee FL 32314-6510

800-482-8293
www.myflorida.com/dor