North Carolina Department of Commerce                                       For Agency Use Only 
               Division of Employment Security 
                      Post Office Box 26504                                      Timely (TL01) 
               Raleigh, North Carolina 27611                                     Untimely (TL02) 
                                                                                 Liable Acquiring Liable (TL03) 
               Application for Partial Transfer of Experience 
                                                                             Date of Transfer:                                    
                            Rating Account 
                                                                             Date of Rate:                                        
       The information requested on this form is to assist in                Rates:   C          P1                       P2       
       determining whether the experience rating account of 
                                                                                 P3              P4                       P5      
       the predecessor employer may be partially transferred to                                                                      
       the successor employer as provided in Section 96-11.7                     FY               
       of the Employment Security Law of North Carolina.                     Approved By:                             Date: 

 Type or Print in Black Ink                                                                                                         
 1. Date part of organization, trade, or business was transferred:                                                                 
 
 2. Enter the percent of payroll related to the: 
 Portion Transferred:       %    Portion Retained:                 %  =  100% 
 
 In calculating these percentages use the three fiscal year period which ended on June 30 immediately preceding the 
 date in Item 1. The payroll, benefit charges, and the experience rating account balance shown on form NCUl 104 as of 
 July 31 immediately preceding the transfer; the payroll and tax from such July 31 to the date of transfer; and also any 
 benefit charges which are made based on wages paid prior to such transfer, will be transferred to the successor and the 
 retained portion on the basis of the percentage shown above. 
 
 3. During the calendar year or the previous five calendar years the portion being transferred from the predecessor paid at 
 least $1500 in wages in North Carolina during the calendar quarter or employed at least one North Carolina worker in 
 any part of 20 different calendar weeks during a calendar year. 
 
 4. All taxes, penalties, and interest based on wages paid by the predecessor employer prior to the date of transfer have 
 been paid. 
 
 5. The predecessor and successor employers do hereby certify that the information contained in this application is true  
 and accurate and mutually consent to and hereby request the transfer of the aforementioned portion of the predecessor's 
 experience rating account in accordance with Section 96-11.7 of the Employment Security Law of North Carolina. 
 
 Note: This application must be signed by the respective employers; by sole proprietor if the employer is/was a 
       proprietorship; by a partner if the employer is/was a partnership; and by a duly elected corporate officer if the 
       employer is/was a corporation. The signatures must be witnessed. 
 
 Predecessor Account Number                       Retained Portion Successor Account Number or Federal I.D. Number 

 Employer Name                                                     Employer Name 

 Signature OF Owner / Partner / Corporate Officer                  Signature OF Owner / Partner / Corporate Officer 

 Title                                            Date             Title                                             Date 

 Witness                                                           Witness 

 Mail this application to the Division of Employment Security at the above address. 
 
 NCUI 603 (Rev. 06/2013)