Department of
WORKFORCE         SERVICES                                               PETITION FOR PARTIAL TRANSFER OF
 Employer Accounts Services • P.O. Box 2981 • Little Rock, AR 72203-2981 EXPERIENCE (A.C.A. 11-10-710(B))
        Telephone (501) 682-3798 • Fax No.: (501) 537-9868
                                         ALL QUESTIONS MUST BE ANSWERED
1.  NAME OF PREDECESSOR OR TRANSFER EMPLOYER:

 ADDRESS (STREET, CITY, STATE, ZIP CODE):

 DWS ACCOUNT NO.:                                                        FED ID NO.:

2.  DATE OF TRANSFER:                                                    3.  PERCENT OF BUSINESS TRANSFERRED:

4.  PERCENT OF BUSINESS RETAINED BY PREDECESSOR:                         5.  GIVE DATE OF FIRST PAYROLL OF THE SUCCESSOR:

5.  IF PREDECESSOR HAS CHANGED OPERATING NAME, ADDRESS OR ACTIVITIES, PLEASE COMPLETE (a), (b), (c), AND (d).
 a.  NAME:

 b.  LOCATION OF BUSINESS (STREET, CITY, COUNTY, STATE, ZIP CODE):

 c.  PRINCIPAL ACTIVITY OF RETAINED BUSINESS:

 d.  PRINCIPAL PRODUCT:

7.  NAME OF SUCCESSOR OR TRANSFEREE EMPLOYER:

 ADDRESS (STREET, CITY, STATE, ZIP CODE):

 DWS ACCOUNT NO.:                                                        FED ID NO.:

 PRINCIPAL ACTIVITY:                                                     PRINCIPAL PRODUCT:

We the predecessor and successor employer, hereby jointly certify that the information provided herein is true and 
correct to the best of our knowledge and belief. Furthermore, we hereby agree that contributions credited and benefits 
charged to the account of the predecessor shall be divided between the predecessor and successor by the transfer 
percentages specified in numbers 3 and 4.

 PREDECESSOR OR TRANSFER EMPLOYER                                        SUCCESSOR OR TRANSFEREE EMPLOYER
Signed:                                                                  Signed:
Title:                                                                   Title:
Date:                                                                    Date:

NOTE:        This must be signed by a corporate officer, partner or proprietor of both the predecessor and successor and  
             be filed with the Department of Workforce Services within thirty (30) days after the transfer.

DWS-ARK-201P (Rev. 7-05)