Mail To: 
 Cashier - Texas Workforce Commission 
 P.O. Box 149037 
 Austin, TX 78714-9037 
 512.463.2731 
 www.texasworkforce.org 
                                                                          WAGE DISTRIBUTION INFORMATION
                                                               FOR PARTIAL TRANSFER OF COMPENSATION EXPERIENCE 
                                           (Please submit wage distribution forms for at least four years, if applicable, prior to the year of acquisition.) 
  
                                                                                                                                                                                                 Audited by ( AE Number) 
Date Quarter Ended                                                                                                    Page No.           of              Pages                                    
 
Successor’s Name                                                                                                       Predecessor’s Name             
                                                                                                                        
Address                                                                                                                Address            
                                                                                                                        
City                               State             Zip Code                                                          City                               State             Zip Code             
                                                                                                                        
Account Number                                                                                                         Account Number              

                                                (INSTRUCTION: Distribute amounts in Col. 3 between Col. 4 and Col. 5) 
                   1                            2                                                                     3                               4                                                5 
                                                                                                                                                                                                        
          Employee’s                  Employee’s Name                           Total                                                                 Total                                      Total  
  Social Security Number       1             st 2           nd            Last  Wages as Reported                                          Wages Applicable                                      Wages Retained 
  (in numerical order)         Initial       Initial       Name                 By Predecessor                                                     To Successor                                  By Predecessor 
 
FOOTINGS FOR THIS PAGE                                                                                                                                                                           
                                                                                                                                                                                                        
COLUMN 3 TOTALS SHOULD EQUAL LINES                                                                                                                                                               
13 & 14  ON EMPLOYER’S QUARTERLY REPORT                                                                                                                                                                 
TOTAL WAGES                                                  Allocate to                                                                                                                         
FOR THIS QUARTER                                        Columns 4 & 5                                                                                                                                       
TOTAL TAXABLE WAGES                               Allocate to                                                                                                                                    
FOR THIS QUARTER                                         Columns 4 & 5                                                                                                                                      
 Prepared By                                                       Phone No. (        )               Ext.            
                                      Individuals may receive, review and correct information that TWC collects  
                                      about the individual by emailing to open.records@twc.state.tx.us or writing  
                                                                                th
                                      to TWC Open Records, 101 E. 15  St., Rm. 266, Austin, TX  78778-0001. 
 C-83 (051515)