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6. Please read carefully.
We hereby certify that the information provided in this application is true to the best of our knowledge and belief. We request that
the transferee be made a successor in interest to the transferor's account and, as such, assume all the resources and liabilities of
the transferor's account. Furthermore, we acknowledge that all contributions, interest and forfeitures due to the agency as of the
date of transfer (by both the transferor and transferee) must be paid in full in order for the application to be approved.
Transferee Signature:
Date:
/
/
Title:
Transferor Signature:
Date:
/
/
Title:
PLEASE SEE ATTACHED PAGE FOR LAW AND RULES APPLICABLE TO THIS APPLICATION AND THE
TRANSFER OF EMPLOYMENT EXPERIENCE.
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JFS 20118 (9/2010)
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