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*046800012*
046800012
SECTION TWO - BASIS FOR LIABILITY CHANGE
1. Are you submitting this form to report that you have transferred all or part of Yes No If No, go to
your existing business or workforce to a different business? question 2.
IMPORTANT: Indiana requires that a business disclose the transfer of assets, including the workforce, between businesses.
Answering no to this question indicates that you did not in any way transfer operational control of all or part of an existing
Indiana business including the workforce. Failure to disclose transfer of operational control of assets is considered a material
misrepresentation under the Act. Please attach documentation which supports the type of transfer for evaluation under IC 22-4-10
and IC 22-4-11.5. For a bankruptcy, you must attach the specific Order approving the sale or transfer of the assets. If you disagree
with the successorship determination of the Agency, you will have 15 days to protest the initial determination in writing per IC 22-4-32.
Select the type that best Reorganization or FEIN Change Bankruptcy Sheriff's Sale/Foreclosure
describes this transfer Purchase/Transfer Franchise PEO/Leasing Agreement Other purchase or transfer
(a) To the best of your knowledge, what percent of the existing business transferred? . %
Please provide any known information regarding the identity of the Acquirer: FEIN
SUTA # Name
(b) What day did operational control transfer to the acquirer? / /
Operational control transfers on the day that the acquirer has a legal right to direct the business operations, even if they do not
immediately exercise the right.
If you answered Yes to Question 1, selected the type of transfer, have answered questions 1(a) and 1(b), and have identified the
disposer to the best of your ability, please go to section 3 to complete the status change request.
2. Are you submitting this form to voluntarily terminate the account and transfer Yes No If No, go to
any experience balance associated to the account to the State? question 3.
An employer may voluntarily terminate an account under IC 22-4-9-2 if they have not had any employment in the current or prior
calendar year. A request for account termination must be filed by January 31st of the year for which it is to be effective.
(a) Have you paid any wages as defined by IC 22-4-4 to anyone engaged in covered Yes No
employment as defined by IC 22-4-8 during the current or prior calendar year?
If you answered Yes to question 2 and to question 2a, go to section 3 to complete the status change. If you answered No to question
2a, you are not eligible to voluntarily terminate the account at this time. If you do not currently have wages or covered employment,
but do not yet meet the requirement for voluntarily terminating your account, please answer question 2 No and complete section 3 to
suspend the account.
3. Are you submitting this form to suspend liability and reporting on the account? Yes No
If an employer ceases to have covered employment during a calendar year, but does not meet the requirement for voluntary
termination or anticipates having covered employment in the future, the employer can request to suspend liability on the account.
Once the account is suspended, the employer may resume reporting for up to four (4) years after the suspension.
Select the type that best Permanent business closure Proprietorship / partnership operating without employees
describe this action Reorganization or FEIN Change Corporation officers working without remuneration
If you answered Yes to question 3 and have selected the appropriate closure description, go to section 3 to complete the status
change.
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