Application for Partial Transfer of Experience

                                       33 South State Street, 10th Floor
                                       Chicago, Illinois 60603-2802 

                          Phone: 800-247-4984  |  Fax: 217-557-1948

TRANSFEREE (SUCCESSOR)                                   TRANSFEROR (PREDECESSOR)

We,  The  undersigned  employing  units,  hereby  jointly  make  application  to  the  Director  of  Employment  Security  under  the 
provisions of Section 1507B of the Illinois Unemployment Insurance Act for the transfer of that part of the experience rating 
record of the TRANSFEROR  which is attributable to the portion of the employing enterprises acquired by the TRANSFEREE. 
We hereby submit the following information in support of our application and as a basis for the Director’s transfer of such 
experience rating record: 

1. Date on which TRANSFEREE acquired a portion of his PREDECESSOR___________________________________

2. Name and address of PREDECESSOR_______________________________________________________________
                                                          (Name) 
   ________________________________________________________________________________________________ 
                       (Trade Name)                       (Address) 
3. Beginning  date  of  the  quarter  for  which  PREDECESSOR  first  had  wages  subject  to  contribution  under  the  Illinois
   Unemployment Insurance Act in the portion acquired by TRANSFEREE ___________________________________

4. In the calendar year during which Predecessor disposed of a portion of his employing enterprises to Transferee, and in
   each of the four calendar years immediately preceding that year, did PREDECESSOR have wages subject to contribution
   under the Illinois Act in the portion acquired by the TRANSFEREE?
    YES     NO  If no, indicate each calendar year within that period in which PREDECESSOR did NOT have such wages
   in said portion:________________________________________________ ___________________________________

5. In the calendar year during which Predecessor disposed of a portion of his employing enterprises to Transferee, and in
   each of the four calendar years immediately preceding that year, did PREDECESSOR have wages subject to contribution
   under the Illinois Act other than the wages attributable to the portion acquired by TRANSFEREE and to portions acquired
   by  other  Transferees,  if  any?    YES      NO  If  no,  indicate  each  calendar  year  within  that  period  in  which
   PREDECESSOR did not have such wages:
   ____________________________________________________________________________________

6. On the date given in item 1, was TRANSFEREE owned or controlled by the same interests which owned or
   controlled his PREDECESSOR immediately prior to that date?     YES     NO  If yes, attach sheet giving complete
   details regarding all elements of such common ownership and control on that date and regarding subsequent changes, if
   any.

                                                         (over) 

   ER-65 (Rev. 10/17)

                   CERTIFICATION - WAIVER - AGREEMENT 

The  undersigned   TRANSFEREE  and  TRANSFEROR  herby  certify  that  the  portion  acquired  by 
TRANSFEREE  was  a  distinct  severable  portion  of  the  employing  enterprises  of  the  Predecessor;  that  the 
information contained in this Application and in any sheets attached hereto is true and correct  to the best of 
their knowledge and belief; and that they execute these documents for the purpose of transferring from the 
TRANSFEROR to the TRANSFEREE that portion of the experience rating record which is attributable to the 
portion of the employing enterprises acquired by the TRANSFEREE. 

TRANSFEROR  hereby  waives  his  rights  to  a  contribution  rate  based  on  the  experience  rating  record 
attributable to the portion of the employing enterprises acquired by the TRANSFEREE. 

TRANSFEREE  and  TRANSFEROR  hereby agree  to  furnish to  the Department of  Employment Security 
any additional allocation of TAXABLE WAGES AND BENEFIT CHARGES which the Director of Employment 
Security may require. Both parties hereby agree that such additional allocation, and any allocation made by 
the Director on the basis of information contained in this Application shall be treated as part of this Application 
for Partial Transfer of Experience. 

TRANSFEREE                                                     TRANSFEROR 

Business Name ______________________                 Business Name ________________________ 

Signed By __________________________                 Signed By ____________________________ 

Official Title _________________________             Official Title ___________________________ 

Date Signed ________________________                 Date Signed ___________________________ 

This application must be signed by owner, partner, or officer of each employing unit. If signed by any 
other person, a power of attorney giving such person individual authority to sign it must be on file.. 

YOU ARE CAUTIONED THAT ONCE AN APPLICATION FOR PARTIAL TRANSFER IS APPROVED BY 
THE  DIRECTOR  OF  EMPLOYMENT  SECURITY,  IT  BECOMES  FINAL  UPON  THE  PARTIES  THERETO 
AND CANNOT SUBSEQUENTLY BE WITHDRAWN BY THEM. 

Please PRINT signatures from above: 

X ___________________________                        X _________________________ 

ER-65 (Rev. 10/17)