Form SPT-UC-247

                         Application and Agreement for Severable
                          Portion Experience Rating Transfer

If you purchased part of an existing business (and checked the “Part” box in Section VI of your
Arizona Joint Tax Application, Form UC-001), you may apply for a portion of the prior owner’s
unemployment tax rate.  Use this form to make application for this severable portion within 180
DAYS OF THE ACQUISITION. Your completed form should be mailed or faxed to the address or fax
number shown below.

REMEMBER  - WHEN YOU PURCHASE A BUSINESS,THE SEVERABLE PORTION
                          IS NOT  AUTOMATICALLY ASSIGNED.
YOU MUST APPLY FOR IT WITHIN 180 DAYS OF THE ACQUISITION        .

Questions about completion of this form or severable portions may be directed to the
Experience Rating Unit at

                          Experience Rating Unit
                          ADES – UI Tax Section
                          P. O. Box 6028
                          Phoenix, AZ  85005-6028

                          Telephone - (602)(602)771-6603248-9101
                                      Extension 5501

                          FAX -  (602) 277-3404532-5564

UC-247 (10/06)UC-247 (8/99)
                                  ARIZONA DEPARTMENT OF ECONOMIC SECURITY
                                               Unemployment Tax- Experience Rating - 911B
                                  PO Box 6028; Phoenix, Arizona 85005-6028; Phone: 602-248-9101 Ext. 5501602-771-6603  FAX 602-532-5564
                                               E-Mail:  uit.experience@azdes.gov
              APPLICATION AND  AGREEMENT FOR SEVERABLE PORTION EXPERIENCE RATING TRANSFER
                           THIS APPLICATION MUST BE FILED WITHIN 180 DAYS OF THE DATE OF ACQUISITION
PREDECESSOR EMPLOYER NAME                                    SUCCESSOR EMPLOYER NAME

1. Did the successor employer continue to operate the acquired portion of the business  ! Yes        !  No
   Effective date of transfer:
2. Enter the TAXABLE wages paid in the last 12 completed calendar quarters preceding the date of acquisition (or for the
   period of existence of the business if less than 12 quarters) AND, if the  business  was  acquired  in the  middle  of  a
   quarter, the wages for the portion of the quarter up to the date of acquisition. List wages by quarter and include:
   Column (1)    Taxable wages for the retained and transferred portions of the business combined.
   Column (2)    Taxable wages attributable to the portion of the business retained by the predecessor.
   Column (3)    Taxable wages attributable to the portion of the business transferred to the successor.
   Column  2  plus Column 3 must equal Column 1.  NOTE:  If the predecessor  acquired another business within  the
   applicable 12 calendar quarters, include the taxable wages from that business.  Any corrections submitted after original
   reports were filed must also be included.
              THE TRANSFER OF A SEVERABLE PORTION OF THE EXPERIENCE RATING ACCOUNT IS NOT MANDATORY
                                               COLUMN 1                         COLUMN 2                                               COLUMN 3
        QUARTER  ENDING                        TAXABLE WAGES                    TAXABLE WAGES                                TAXABLE WAGES
                                               BOTH PORTIONS                    PREDECESSOR PORTION                     SUCCESSOR PORTION

                             TOTAL
3. The undersigned agree to the transfer of the predecessor's experience rating account applicable to the distinct and
   severable portion of the business acquired by the successor.  It is further understood that if all requirements are met:
   (1) the amount of the experience rating account transferred will be a percentage of the predecessor's total experience
        rating account;
   (2) both parties shall receive copies of the predecessor's Benefit Charge Notices, and each shall be subject to its
        proportionate share of charges for three fiscal years; and
   (3) the predecessor may be required  to submit amended wage reports for the quarter in which the transfer occurred.
PREDECESSOR EMPLOYER NAME                                     SUCCESSOR EMPLOYER NAME

ADDRESS                                                       ADDRESS

ACCOUNT NO.                        PHONE NO.                  ACCOUNT NO. OR FEDERAL  I.D.                          PHONE NO.

SIGNATURE OF OWNER/PARTNER/CORPORATION OFFICER                SIGNATURE OF OWNER/PARTNER/CORPORATION OFFICER

TITLE                              DATE                       TITLE                                                 DATE

                                               Equal Opportunity Employer/Program
                                        For alternative format/reasonable accommodations: contact the UI Tax Office