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 UIA 1184-1                                                                                                          Authorized by 
 (Rev. DRAFT)                                                                                                      MCL 421.1 et seq. 
                                                                         
                                                  STATE OF  MICHIGAN 

 GRETCHEN  WHITMER     DEPARTMENT              OF LABOR AND             ECONOMIC    OPPORTUNITY      SUSAN R. CORBIN 
           GOVERNOR                            UNEMPLOYMENT INSURANCE              AGENCY                 DIRECTOR 
 
                     Agreement on Partial Transfer of Business Certification 
 UIA Employer Account Number:                                                       Mail Date: 
 
 The Unemployment Insurance Agency (UIA) received notice that you (the transferor) transferred less than 75% of your 
 business assets to an individual, individuals, or other legal entity (the transferee). In accordance with Section 22 of the 
 Michigan Employment Security (MES) Act, 

       (a)  If an employer subject to this MES Act transfers subsequent to June 30, 1954 any of these 
            assets of his business by any means otherwise than in the ordinary course of trade, such 
            transfer shall be deemed a “transfer of business” for the purpose of this section. 
       (b)  Notwithstanding the provisions of subsection a), a transfer of assets to a transferee which 
            involves less than 75% of transferor’s assets shall not be deemed a transfer of business 
            unless all of the following occur: 

            (1)  UIA is notified of the transfer of assets by the transferor or transferee within 30 days after 
              the end of the quarter in which the transfer occurred. 
            (2)  UIA receives within 30 days after the request therefore a written approval by the transferor 
              and transferee of a rating account transfer determined in accordance with provisions of 
              subsection d) of this section. 
            (3)  In case of a transferee who elects under Section 25 to become subject as of the transfer 
              date, UIA receives the election within 30 days after the mailing of a notice of his right to 
              elect. 

 The requirement for a partial rating account transfer has been met based on [Section 22(b)(1)]. To comply with the 
 provisions of Section 22(b)(2) and (3), authorization is required from you (the transferor) and the transferee that a partial 
 rating account transfer is agreed on.  Your signatures below certify that: 

       1)  The transferee has used the assets acquired from you (the transferor) in the continuation of 
            part of your business operation; 
       2)  The payroll information requested on the reverse of this report is correct to the best of your 
            knowledge and should be used to determine the amount of money which will be deducted from 
            your rating account and credited to the transferee’s account. 
       3)  The transferee, if not a liable employer on the date of transfer, is electing to become a liable 
            employer under Section 25 of the MES Act, effective as of the date of transfer, for the purpose 
            of obtaining a partial rating account transfer; and lastly, 
       4)  That you (the transferor) and the transferee have agreed to this partial account transfer. 
 
            TRANSFEROR                                                   TRANSFEREE 
 
 Signature                                                               Signature 
 
 Print Name                                                              Print Name 
 
 Title                                                                   Title 
 
 Date                                                                    Date 
 Return this completed form to: P.O. Box 8068, Royal Oak, MI 48068-8068, or fax 1-517-636-0014, within 30 calendar days 
 from the mail date shown above. 
 
                                               LEO is an equal opportunity employer/program. 



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 UIA 1184-1                                             Instructions and Worksheet 
 (Rev. DRAFT) 
 Page 2 

 1.  Enter the total (gross) and taxable wages you paid during the 4 completed calendar quarters prior to the transfer date.  (Total wages is represent the gross 
  amount paid to all employees.  Taxable wages is the amount on which contributions (taxes) were payable for all employees.)  Figures entered were taken from 
  UIA records. If an amount is not correct, provide a full explanation when you submit this report. 
 
        Qtr.     Yr.               Qtr.       Yr.                      Qtr.        Yr.               Qtr.      Yr.      
        Total    $        +   Total           $                    +   Total       $               + Total     $        =   Total     $ 
        Taxable  $        +   Taxable         $                    +   Taxable     $               + Taxable   $        =   Total     $ 

 2.  Enter the portion of above wages allocatable to the transferred portion of the business.  Include all of the wages paid to employees who performed all services 
       in connection with the transferred portion of the business, during the 4 calendar quarters indicated, regardless of whether they were employed on the transfer 
       date or had been separated at some time prior.  This amount should also include the proportionate share of wages for employees who performed some, but 
       not all, of their services for the transferred portion of the business.  Use the space provided in the table below to accumulate the amounts required. 
 
        Qtr.     Yr.               Qtr.       Yr.                      Qtr.       Yr.                Qtr.      Yr.      
        Total    $        +   Total           $                    +   Total      $                +   Total   $        =   Total     $ 
        Taxable  $        +   Taxable         $                    +   Taxable    $                +   Taxable $        =   Total     $ 
 
 3.  Enter the total (gross) wages and taxable wages paid from the beginning of the quarter in which the transfer occurred through to the transfer date, that is 
       allocatable to the transferred portion of the business.  Do not complete this if the transfer occurred on March 31, June 30, September 30 or December 31 of 
       any year. 
                                                                                                                             Total     $                               
                                                                                                                             Taxable  $                                
 4.  In Section A below, list the name, Social Security number and percent of time spent by each employee who performed services in connection with the 
       transferred portion of the business during the 4 completed quarters preceding the transfer date and during the portion of the calendar quarter, in which the 
       transfer occurred. Attach additional sheets if necessary - computer printouts are acceptable.  Section B is optional.  However, you may find it useful 
       in completing the wage totals required under items 2 and 3. 
 
  Section A                                   Section B  (Optional)                                                                       
  This portion MUST   be completed.           Qtr.       Yr.                  Qtr.      Yr.               Qtr.      Yr.       Qtr.        Yr. 
                                       % of 
            NAME      SSN            TIME       TOTAL              TAXABLE      TOTAL    TAXABLE             TOTAL   TAXABLE    TOTAL                         TAXABLE 
                                                                                                                                          
              TOTALS  Transfer to   Item 2    $          $                    $         $                 $         $         $           $ 
 






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