ADMINISTRATIVE OFFICE 
                                                                 45 SOUTH FRUIT STREET
                                                                 CONCORD, NEW HAMPSHIRE 
                                                                  03301-4857
GEORGE N. COPADIS, COMMISSIONER
RICHARD J. LAVERS, DEPUTY COMMISSIONER

 Name                                                                                                              Account #

                               TRADE, BUSINESS, AND WORKFORCE TRANSFER REPORT
 (This report must be completed within 30 days of an employer having sold or transferred all, or a portion of, its trade, business or workforce. RSA 282-A, EMP 303.15)
                                      SALE OF BUSINESS OR ENTITY CHANGE SECTIONS
 1.    Changed to (check one)         Sole Proprietorship Partnership    Corporation   LLC Date of Change
 2.    Business Sold or Leased:           Yes             (complete information below) No
                               % of Assets Sold or Leased:
                                          Sold/Leased to:         Name
                                                                  DBA
                                                                  Address

 3.    Do you still furnish employment in New Hampshire under this account number?
                               Yes        If YES, Please explain:
                               No         If NO, Specify last date of employment in NH:
                                          TRANSFER OF WORKFORCE SECTION
 4.    Date of Transfer All or Portion of NH Workforce:
 5.    Business Workforce Transferred to (Transferee):            Name
                                                                  DBA
                                                                  Address

 6.    Number of NH Employees Transferred:
       (Must complete the TRADE, BUSINESS, AND WORKFORCE TRANSFER REPORT - TRANSFERRED EMPLOYEES form or 
       attach a separate list providing transferred employees names, social security numbers, and gross wages for the last 4 
       completed calendar quarters prior to the date of transfer)
 7.    Number of Employees Retained:
 8.    Is there any common ownership, management or control between parties (Transferor and Transferee)?
                                      Yes No
                 If YES, Please explain:
 9.    Attach a list of the Owners, all Partners, Authorized Corporate Offi cers and Authorized Members of Limited 
       Liability Companies.
 10.   I (we) declare under penalty of law (RSA 282-A:166) that I (we) prepared this report, including any accompanying 
       schedules and attachments, to the best of my (our) knowledge and belief, a true, correct, and complete report based on 
       all the information relating to the matters required to be reported in this report of which I (we) have any knowledge.

                 Name                     Title                                        Date

                 Signature                Address                                      Telephone #

 NHES is a proud member of America’s Workforce Network and NH Works. NHES is an Equal Opportunity Employer and complies with the NHES 0046
  Americans with Disabilities Act. Auxiliary aids and services are available upon request of individuals with disabilities                                             R 10/15
 
 Telephone (603) 224-3311   Fax (603) 225-4323   TDD/TTY Access: Relay NH 1-800-735-2964   Web site: www.nhes.nh.gov

Preceding Qtr

Preceding Qtr
Submit By Email

Account #
Preceding Qtr

Gross Wages (Last 4 Completed Calendar Quarters Prior to Transfer) Most Recently Completed Qtr

Transferred Employees

TRADE, BUSINESS, AND WORKFORCE TRANSFER REPORT
Employee Name

Employer Name

SocialSSN # - Last FourSecurity # 
SSN # - Last Four