APPLICATION FOR PARTIAL TRANSFER OF EXPERIENCE 
                      SCHEDULE C - Allocation of Benefit Charge Totals (Claims) 

Fax number: 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
                             Total Benefit Charges                              Balance of 
      PERIOD COVERED BY                   under    Benefit Charges              Benefit Charges 
STATEMENT OF BENEFIT CHARGES PREDECESSOR’s         Attributable to              Attributable to 
      FORM BEN-118, ISSUED   Account Number        TRANSFEREE                   TRANSFEROR 
                                                                                (Col. 2 less Col. 3) 

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ER-68 (Rev.  /8 17)