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Mail To: This form can be completed online at
Cashier - Texas Workforce Commission www.texasworkforce.org
P.O. Box 149037
Austin, TX 78714-9037
512.463.2731
TRANSFER OF COMPENSATION EXPERIENCE QUESTIONNAIRE
PREDECESSOR IDENTIFICATION SUCCESSOR IDENTIFICATION
Employer Name Employer Name
Address Address
City, State, ZIP City, State, ZIP
Account No. Account No.
Date of Acquisition
Chapter 204, Subchapter E of the Texas Unemployment Compensation Act requires the transfer of compensation experience from a predecessor employer to a
successor employer, under certain circumstances. To determine whether this provision is applicable to you, this questionnaire must be completed and returned to
TWC. . If a partial acquisition occurred, the predecessor/successor may jointly submit information regarding a partial transfer of experience.
1. On the date of the acquisition, was the previous owner(s), or any partner(s), officer(s), shareholder(s), other owner(s) or a person related by blood or marriage to
any of these individuals, holding a legal or equitable interest in the predecessor business, also an owner, partner, officer, shareholder, or other owner of a legal or
equitable interest in the successor business?
Yes No
If “Yes”, please indicate below the predecessor’s relationship to the successor.
Myself Spouse* Mother Father Son Daughter
Son-in–law* Daughter-in-law* Mother-in-law* Father-in-law* Other (Specify)
*Termination of a marriage by divorce or the death of a spouse terminates relationships by affinity created by that marriage unless a
child of that marriage is living, in which case the marriage is treated as continuing to exist as long as a child of that marriage lives.
If “No”, on the date of the acquisition, did the previous owner(s), partner(s), officer(s), shareholder(s), other owner(s) or a person related by blood or marriage to
any of these individuals, holding a legal or equitable interest in the predecessor business, hold an option to purchase such an interest in the successor
business?
Yes No
2. After the acquisition, did the predecessor continue to do any of the following:
• Own or manage the organization that conducts the organization, trade, or business?
• Own or manage the assets necessary to conduct the organization, trade, or business?
• Control through security or lease arrangement the assets necessary to conduct the organization, trade, or business?
• Direct the internal affairs or conduct of the organization, trade or business?
Yes No
If yes, describe:
I hereby certify that the preceding information is true and correct, and that I am authorized to execute this Transfer of Compensation Experience Questionnaire on behalf of
the Employing Unit named herein. (This report must be signed by the owner, officer, partner OR individual with a valid Written Authorization on file with the Texas
Workforce Commission.)
Date of signature:
Month ___ Day ___ Year ___ Sign here ___________________________________ Title _______________
Driver's license number ___________ State ______ E-mail address ___________________________________
Individuals may receive, review, and correct information that TWC collectsthabout the individual by emailing toopen.records@twc.state.tx.us or writing to TWC Open
Records, 101 East 15 St., Rm. 266, Austin, TX 78778-0001.
C-38 (071515)