RESET FORM                                         UIA 1027                                          Authorized by
                                                                           (Rev. 0 -2 20)                                    MCL 421.1, et seq.
                                                                                                         State of Michigan
     BUSINESS TRANSFEROR’S NOTICE                                                      DEPARTMENT OF LABOR AND ECONOMIC OPPORTUNITY Y
                                                                                              UNEMPLOYMENT INSURANCE AGENCY
     TO TRANSFEREE OF UNEMPLOYMENT
     TAX LIABILITY AND RATE                                                                   GRETCHEN WHITMER               SUSAN R. CORBIN
                                                                                               GOVERNOR                      ACTING DIRECTOR

Regardless of any agreement between the parties to the transfer,           • cumulative benefit charges for the most recent five years,
the Michigan Employment Security (MES) Act provides that                   •        a listing  of all  individuals  currently  employed  by the
when a business is sold (or otherwise transferred), the buyer                       transferor, and
(or other transferee) of the business may be liable to pay the             •        a listing of all employees separated from employment with
unpaid unemployment taxes and interest, and may receive the                         the transferor in the most recent 12 months.
unemployment  tax  rate,  penalty,  and  the  benefit charges  of  the     This obligation extends to the transferor’s  real estate broker, 
seller (or other transferor).*                                             other agent, or attorney.
The law requires the transferor of a business, or the transferor’s real  The information submitted on this form must be current as of the 
estate  broker  or  other  agent  or  attorney,  to  complete  and  date it is signed.  However, this form may be given to a prospective 
deliver  this  form  to  the  transferee  of  the  business.  Section  transferee within 90 days of the date it was signed; the form must 
15(g)  of  the  MES Act requires the seller (or other transferee) of  be delivered to the prospective transferee not less than two calendar 
the business at least two calendar days (not including Saturday,  days before the transferor’s acceptance of the offer.
Sunday, or legal holiday) before the transferor’s acceptance of the 
transferee’s offer to acquire the business to disclose:                    Failure of the business transferor or transferor’s agent to provide 
                                                                           correct information is a misdemeanor, punishable by up to 90 days 
   • the transferee’s outstanding unemployment tax liability,
                                                                           imprisonment and/or fine of up to $2,500.00.  Civil liability for 
   • unreported unemployment tax liability,
                                                                           consecutive damages may also apply, as well as other remedies 
   • the tax payments,
                                                                           provided by law.
   • tax rates,
*In general, a person or business that acquires the organization, trade, business, or 75percent or more of the assets of a business will be liable for
unemployment taxes and interest due the Unemployment Insurance     Agency (UIA) from the seller (or other transferor) of the business at the time of
the transfer, up to the reasonable value of the business minus any secured interest in assets.
1.   Provide a list of the names, addresses, and Social Security numbers of all your employees as of the date you or your agent or attorney
     signs this form.  This will give the transferee the potential number of individuals for whom unemployment tax must be paid, and of
     the potential number of claimants for unemployment benefits.
2.   Provide a list of the names, addresses, and Social Security  umbersN  of all your employees separated from employment for any
     reason in the most recent 12 months prior to the date this form is signed.  This will give the transferee the potential current charges
     to their account.
3.   (a) What is the amount of unemployment taxes you have reported to the UI Aas owing, but have not yet paid? 
     ____________________________
    (b)What is the interest you owe the UI Aon this account?  __________________________
4.   (a) Which quarterly unemployment tax reports (give calendar quarters and calendar years) are unfiled with the UIA? (Ex: 1/2016)

     (b)How much do you owe in unemployment taxes for these unfiled quarters?  (The UI Amay assess interest and penalties on
         this amount.  Interest accrues at 1.0 percent per month, not to exceed 50 percent.) _______________________
*All of the information you will need to complete question 5 is shown on your annual rate determinations (Form UIA 1771) for each of
the years involved.  See the next page of this form for the procedure for calculating tax rate from the information below.  If you acquired
the business less than five years ago, include information only for the period you have had the business, and attach the copy of this form
you received from the transferor when you acquired the business (if you acquired the business after April 1, 1990).
5.   In the space provided, indicate figures from the 5 most recent years, ending the most recent past June 30th, for the following:
    (a) the unemployment tax (contribution) payments made in each of those years;
    (b) the unemployment benefit charges to your account in each of those years;
    (c) the taxable wages used in those years
    (d) the computed unemployment tax rate plus the Section 18(d) penalty, if applicable, for the current and each of the past five
     calendar years, even if you have paid the rate under protest, and/or you have appealed the rate;
                                                12 Months Ending   12 Months Ending       12 Months Ending 12 Months Ending     12 Months Ending
                                                         6/30/____     6/30/____               6/30/____       6/30/____              6/30/____
     a. Contributions (taxes) Paid
     (Includes SUTA Rate Penalty monies)
     b. Benefit Charges
     c. Taxable Wages

UIA 1027
Rev. 05-16
Page 2
                                            Calendar Year        Calendar Year     Calendar Year Calendar Year          Calendar Year
                                            20__                   20__            20__          20__                    20__
      d. Unemployment Tax Rates                              %           %               %                            %             %
          Non Reporting Penalty                              %           %               %                            %             %
          Obligation Assessment                              %           %               %                            %             %
          Solvency Rate                                      %           %               %                            %             %
          TOTAL                                              %           %               %                            %             %

      (e) the Actual Reserve as of the most recent past June 30th:_____________________
      (f) the Required Reserve as of the most recent past June 30th:___________________
      (g) the Total Payroll for the 12 months ending the most recent past June 30th:____________________
CERTIFICATION: I certify that the information contained on this form is accurate and complete to the best of my knowledge and 
               belief.  I understand that criminal and civil penalties may apply for failure to provide accurate information on this form.
The person signing this form below is the:           Business Transferor                 Transferor’s Real Estate Broker
                                                   Agent of Transferor                   Attorney for Transferor
Name of Business: _____________________________________________    UI AEmployer Account No.:_____________________
Signature: ____________________________________   Date: ____________________   Telephone: _________________________ 
Typed or Printed Name of Signer: __________________________________________________________
Title of Signer: ________________________________________
NOTE TO TRANSFEREE:  The information on this form may be up to 90 days old.  Inquire from the Transferor as to updated information.
                  CERTIFICATION OF RECEIPT OF INFORMATION BY PROSPECTIVE TRANSFEREE
Name: _______________________________________________     Date: __________________________
Signature: ____________________________________________     Telephone: ______________________

                                            UNEMPLOYMENT TAX RATE
A tax rate is composed of the Chargeable Benefits Component (CBC), the Account Building Component (ABC), and the 
Nonchargeable Benefits (NBC).  All rates are figured using the following calculations as provided by Section 19(a)(1) of the MES Act.
            Chargeable Benefits Component (CBC):                                   Account Building Component (ABC):
               60 months of benefit charges = CBC                             (Required Reserve minus Actual Reserve) X 0.50 = ABC
               60 months of taxable payroll                                                 12 months of total payroll
            The result is rounded up to the next higher 0.1%             The result is rounded up to the next higher 0.1%
            The maximum value for the CBC is 6.3%                        The maximum value for the ABC is 3.0%
Nonchargeable Benefits Component (NBC): 
If there were Benefit Charges in any of the 5 years shown in question 5b of this form, the NBC is 1.0%.  If the CBC was equal to 
0.1%, the NBC is 0.5%.  If there were no Benefit Charges for those 5 years, the NBC is 0.1%.  If there were no Benefit Charges for 
more than 5 years, the NBC may be as low as 0.06%.  See Section 19(5) of the MES Act.

Obligation Assessment (OA):
Section 26a of the MES Act granted the State of Michigan the authority to issue bonds to reduce or eliminate Federal debt incurred by 
the Unemployment Insurance Agency Trust Fund.  On December 29, 2011, the State of Michigan through the Michigan Finance 
Authority, issued $3,320,951,556.55 in bonds and retired the debt and accrued interest.  The Obligation Assessment (OA) represents 
the amount required by law to repay the bonds.  The OA is levied against all contributing employers and is part of the annual tax rate; 
however, the OA is not credited to the employer’s experience account.  The OA is added to the Total Tax Rate.  See Fact Sheet #146 
for further information.  For tax rate year 2011 only there was no OA in effect, but there was a solvency rate for employers with a 
negative reserve balance.  (If applicable, see Form UIA 1771 for the year 2011 to determine if , those rates apply to your account.)

Non-Reporting Penalty:
If any or all quarterly tax reports required for the computation of a tax rate are missing, a non-reporting penalty of 3% is added to the 
Total Tax Rate in accordance with section 18(2) of the MES Act.

Total Tax Rate:  The total rate is calculated by adding the three tax components (CBC + ABC + NBC) plus the OA, and non-reporting 
penalty, (add your 2011 solvency rate) if applicable.

          DIRECT ANY ASSISTANCE IN COMPLETING THIS FORM  TO THE OFFICE OF EMPLOYER OMBUDSMAN AT 
                                  1-855-484-2636 TTYService is available at 1-866-366-0004
                  THIS FORM MUST BE PROVIDED TO PROSPECTIVE PURCHASERS.
                                            UIA is an equal opportunity employer/program.