State Form 23299 - Report Of Transfer - Partial Sale - 2006
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2REPORT OF TRANSFER - PARTIAL SALE
To be filed by the previous owner (disposer)
State Form 23299 (R4 / 5-06)
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
10 N. Senate Avenue
Indianapolis, IN 46204-2277
Local: 317-232-7436 Toll Free: 1-800-8916499 Fax 317-233-2706
NOTE: If as the predecessor/disposer you have transferred a portion of your organization, trade or business, according
to IAC 3-4-12, a percentage of your experience balance shall be transferred to the successor/acquirer. When an employer
acquires a distinct and segregable portion of the organization upon application he assumes the position of the predecessor
with respect to all the resources and liabilities of the predecessor's organization. Reference Indiana Code 22-4-10-6.
This report must be received within 30 days immediately following the date of the disposition or not later than 10 days after
notification from this agency. Reference Indiana Code 22-4-10-6-b. Failure to complete this form in its entirety
may result in a departmental determination of the percentage of experience balance to be transferred.
THIS REPORT MUST BE FILED IF:
You sold, leased, or disposed of a distinct and segregable portion of your organization and
payroll will continue to be paid under your current Federal ID number.
If you disposed of, or leased all of your Indiana business or assets, do not complete this form. You are required to complete State Form
46799, Report of Transfer - Complete Sale.
OFFICE USE ONLY
Please type or print in Ink.
Disposition
Date change became effective: (mm/dd/yy)
________________
Date
Disposition
1. Disposer's Indiana SUTA No.:__________________(_____) FEIN:
Code
Audit
Legal name of employing unit:
Examiner
Date
d/b/a:
Completed
Merit Rate
Business Activity:
Requested
Reassigned
g
Current Address
Account #
City ______________________________________________State:________ZIP Code
Contact person:
Telephone No.
Ext:
2. Acquirer's Indiana SUTA No.:
(
)
FEIN:
Legal name of employing unit:
d/b/a
Business Activity:
Current Address
City
State:
ZIP Code
Contact person:
Telephone No.
Ext:
The percentage listed will be the experience balance transferred to the acquirer.
3. What percentage of your operations were disposed of?
4. Number of employees retained by you.
5. Number of employees rehired by the new entity.
6. List all location that were sold or disposed of. Please attach additional sheets if needed.
a.
b.
7. List any Indiana a business operations retained by you. Please attach additional sheets if needed.
a.
b.
I further certify that I am the owner or authorized agent of the above mentioned entity.
_________________________________________
___________________________
Signature of DISPOSER or Authorized Agent
Signature of DISPOSER or Authorized Agent
Telephone Number
Telephone Number
Date
Date
Remarks:
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