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APPLICATION FOR PARTIAL TRANSFER
OF EXPERIENCE SCHEDULE- A
Allocation of Quarterly Taxable Wage Totals
Fax: 217-557-1948
We, the undersigned, do hereby certify that the information given below is, to the best of our
knowledge, true and correct, and we submit said information as part of the Application for Partial
Transfer of Experience under Section 1507 B of the Illinois Unemployment Insurance Act
TRANSFEREE TRANSFEROR
Employer Account No. __________________ Employer Account No.___________________
Business Name ________________________ Business Name ________________________
Signed By ____________________________ Signed By ____________________________
Official Title __________________________ Official Title __________________________
Date Signed __________________________ Date Signed __________________________
1 2 3 4
Balance of
TAXABLE Wages TAXABLE Wages TAXABLE Wages
QUARTER ENDING Reported by Attributable to Attributable to
PREDECESSOR TRANSFEREE TRANSFEROR
(Col. 2 less Col. 3)
9-30-
12-31-
3-31-
6-30-
9-30-
12-31-
3-31-
6-30-
9-30-
12-31-
3-31-
6-30-
ER-66 (Rev. 8-17)
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