Department of Workforce Development
Division of Unemployment Insurance                                                                       Report of Business Transfer
PO Box 7942                                                                                              (Sale, Acquisition, or Reorganization)
Madison, WI 53707                                                                                        Section 108.16(8) Wisconsin Statutes

Telephone: (608) 261-6700
Fax: (608) 267-1400                                                                  Personal Information you provide may be used for secondary 
http://dwd.wisconsin.gov/ui                                                          purposes [Privacy Law s. 15.04(1)(m), Wisconsin Statutes].  Provision 
                                                                                     of your social security number (SSN) is voluntary; not providing it 
                                                                                     could result in an information processing delay.
1.  Former Owner/Operator
Employer Legal Name                                                Unemployment Insurance Account Number Telephone Number

Trade Name                                                         Federal ID Number                     Form of Ownership           (Check one)
                                                                                                         Individual                             Partnership
Current Mailing Address (Street or PO Box, City, State, Zip Code)                                        Corporation                            Limited Partnership
                                                                                                         Limited Liability Co.
                                                                                                         LLC Electing to be Treated as a Corporation
                                                                                                         Other:   
Physical Location of Transferred Business

Name(s) of Partner(s), Member(s), Stockholder(s)                                                                                                Ownership
                                                                                                         SSN
Continue on additional page if necessary                                                                                                        Percentage

2.  New Owner/Operator
Employer Legal Name                                                Unemployment Insurance Account Number Telephone Number

Trade Name                                                         Federal ID Number                     Form of Ownership           (Check one)
                                                                                                         Individual                             Partnership
Current Mailing Address (Street or PO Box, City, State, Zip Code)                                        CorporationState of Incorporation      Limited Partnership
                                                                                                         Limited Liability Co.
                                                                                                         State of Registration
                                                                                                         LLC Electing to be Treated as a Corporation
                                                                                                         State of Registration
                                                                                                         Other:   
Name(s) of Partner(s), Member(s), Stockholder(s)                                                         SSN                                    Ownership
Continue on additional page if necessary                                                                                                        Percentage

3.  Relationship Between Parties in 1 and 2 Above
Are the new owner/operator(s) the same or related to the former owner/operator(s)?  For example, married, parent/child, common 
partners, stockholders, officers or parent business and subsidiary.
Yes        No      If yes, identify the relationship(s)

4.  Effective Dates
Date transfer                                    Date last operated by                                   Date first operated by 
became effective   ____/____/____                former owner/operator ____/____/____                    new owner/operator                ____/____/____

5.  Options for New Owner/Operator
You may have an option to acquire the Unemployment Insurance experience of the former owner.                        If the date of                         You must 
An applicaton to acquire this experience must be filed by the appropriate date.  See chart at right.                 change is:                            apply by:
Check one of the following statements                                                                               Jan. 1 to March 31                     July 31
This is my application to acquire the account experience of the former owner                                      April 1 to June 30                       Oct. 31
I do not want to acquire the account experience                                                                   July 1 to Sept. 30                       Jan. 31
I have not yet received the former owner's account information                                                    Oct. 1 to Dec. 31                        April 30
UCT-115-E (R. 06/08/2016)

     6.  Method of Transfer
Sale                                         Foreclosure                         Sale of corporate stock       Management contract
Lease                                        Cancellation of lease               Merger or consolidation       Inheritance
Reorganization (change                       Bankruptcy sale                     Receivership                  Other:
of legal form)
7.  Assets Transferred
Real Estate                                  Machinery and equipment             Franchises & licenses         None
Inventories                                  Furniture and fixtures              Goodwill                      Other (explain):
Contracts                                    Accounts Receivable                 Customer lists
8.  Continuation of Business
Has the new owner/operator continued to operate the same business activity without interruption?                                  Yes  No
Has the new owner/operator continued to operate the same business activity in the same location?  (If No, give 
address of new location below).                                                                                                   Yes  No
If you answered "No" to either question above, explain fully

New Street Address

City                                                                             State                         Zip Code

9.  Number of Employees
How many employees worked in the                                                 How many employees continued with the new
transferred business just prior to transfer?                                     owner/operator?

10. Identify Nature of Business Transferred
What specific business activity was transferred?

11.  Total or Partial Transfer
Total transfer  of former owner/operator's Wisconsin business operations
What is the former owner/operator's last date of payroll? ___/___/______
Provide explanation if last date of payroll is after the transfer effective date

Partial transfer  of former owner/operator's Wisconsin business operations
Type of business kept by former owner/operator                      Trade Name                                 Number of employees kept

Business location street address

City                                                                             State                                    Zip Code

Estimate the percentage of former owner/operator's defined (taxable) payroll incurred in the transferred 
portion during the 12 months immediately preceding the transfer                                                                          %

12. Signature of Authorized Representative Required:         This report is submitted on behalf of:
Former Owner Authorized Representative Name and Position            Signature                            Date             Phone Number
                                                                                                                          (           )
New Owner Authorized Representative Name and Position               Signature                            Date             Phone Number
                                                                                                                          (           )
Both:  Signatures of authorized representatives of both the former and new owners are required above
Contact Person Name and Position                                    Contact Phone Number/Email address
                                                                    (           )

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