Mail To: 
Cashier - Texas Workforce Commission 
P.O. Box 149037 
Austin, TX 78714-9037 
512.463.2731 
www.texasworkforce.org 
                                                                                              
                                 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. 
 
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. 
 
2. 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                   
    
3.  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 DECLARE                         that the information contained herein is true and correct to the best of my knowledge. 
 
SIGNATURE  _____________________________________TITLE                                                                                DATE                       
 
(Must be signed by an owner, partner, officer or individual for which a valid Written Authorization is on file with the Texas Workforce Commission). 
 
Individuals may receive, review, and correct informationth                      that TWC collects about the individual by emailing to open.records@twc.state.tx.us 
or writing to TWC Open Records, 101 East 15  St., Rm. 266, Austin, TX 78778-0001. 

C-38 (052013)