UIA 1184                                                                                                 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 
 
                   Notification of Partial Transfer of Business 
                                 Additional Information Required 
 UIA Employer Account Number:                                                  Mail Date: 
 
 On [mm/dd/yyyy], the Unemployment Insurance Agency (UIA) received notice that a portion of your 
 business was transferred to: 
 
 As a result of this transfer, the transferee has been assigned a pro rata (proportional) share of your 
 Experience Rating Account. 
 
 The percentage of transfer is based on the wages of employees whose services were performed in 
 connection with the transferred portion of your business during the four (4) calendar quarters complet- 
 ed prior to the transfer date. 
 
 To ensure the correct amount of your Experience Rating Account transfer and to properly allocate 
 any unemployment benefits which may currently be erroneously charged to your account, complete 
 the back of this form and return it within 30 calendar days from the mail date shown above.  If you do 
 not respond timely to this request, a rate transfer determination will be made based on information 
 available and may result in a no transfer of rating or benefit charges. 
 
 I certify that the information contained in this report is true and correct to the best of my knowledge. 
 
 Signature                                    Date 
 
 Print Name                                   Title 
 
 Return the 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. 

 UIA 1184 
 (Rev. DRAFT)                                         Instructions and Worksheet 
 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    $          $                      $         $                 $         $         $           $