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)