Ohio Department of Job and Family Services 
                                  Office of Unemployment Insurance Operations 
                            APPLICATION FOR VOLUNTARY SUCCESSORSHIP 
  TRANSFER OF CLEARLY SEGREGABLE AND IDENTIFIABLE PORTION 
                                                                
 Successor Employer Name 
  
 Successor Employer ID  Note: If you do not have an Employer ID, you must submit a Report        Successor Phone Number 
 to Determine Liability (JFS 20100) with this application. 
  
 Successor Street Address  (Please do not enter a P.O. Box) 
  
 City, State, ZIP 
  
 Predecessor Employer Name 
  
 Predecessor Employer ID                                                                         Predecessor Phone Number 
  
 Predecessor Street Address  (Please do not enter a P.O. Box.) 
  
 City, State, ZIP 
  
 What was the date of transfer?                                What percentage of the business was purchased? 
  
 Provide a detailed description of the portion or division of the business that was transferred. 
  
 You must submit a list of the individuals who were transferred from the clearly segregable and identifiable portion and immediately 
 employed by the successor after the date of transfer. The information should include the following: Employee Social Security Number, 
 Employee Last Name and Employee First Name. 
  
  Failure to furnish this information with your application will result in processing delays and possible denial of your application. 
 
JFS 20119 (Rev. 7/2020)                                               unemployment.ohio.gov                                                                          Page 1 of 2 

ACKNOWLEDGMENT  
 
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 clearly segregable and identifiable portion of 
the transferor's account and, as such, assume all the resources and liabilities attributable to the segregable and 
identifiable portion.  
 
We acknowledge that all unemployment insurance tax, interest and penalty(s) due to the agency as of the date of 
transfer (by both the predecessor and successor) must be paid in full for the application to be approved.  
 
Finally, we acknowledge that we have read and agree to the law and rules applicable to this application for the 
transfer of employment experience. 
 
Predecessor Signature               Date 
                                     
Printed Name and Title 
 
Phone Number 
 
Successor Signature                 Date 
                                     
Printed Name and Title 
 
Phone Number 
 
This form must be signed by an authorized representative of both the predecessor and successor. Failure to 
 furnish the signatures of both parties will result in a potential denial of the application. 
 
 P.O. Box 182404     Columbus, OH 43218-2404     (614) 466-2319     unemployment.ohio.gov 
 
JFS 20119 (Rev. 7/2020)                                               unemployment.ohio.gov                                                                          Page 2 of 2