Form 21c - Statement Form To Correct Information Previously Submitted
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1FORM 21C (Rev. 5/00)
STATEMENT TO CORRECT INFORMATION PREVIOUSLY SUBMITTED
Unemployment Insurance Division of South Dakota
P.O. Box 4730
Aberdeen, South Dakota 57402-4730
UI Rate ______________________
Name ____________________________________________________________________________________
IF Rate ______________________
Address ___________________________________________________________________________________
Account Number _________________________
Total ______________________
Amount Reported on Original Return
Correct Amount
Qtr/Yr
Total Wages Paid This
Wages in Excess of
Total Wages Paid This
Wages in Excess of
Social Security #
Employee Name
to be
Quarter
$7,000
Quarter
$7,000
Corrected
1
2
3
4
5
6
7
8
Explanation:
Separate Report is Required for
Quarter
Quarter
Quarter
Quarter
I certify that this report is
correct and no part of the
Each Year
Code
3/31/
6/30/
9/30/
12/31/
Total
contribution was or will be
paid by any employee.
Net Change in Total Wages
Send original to the
Unemployment Insurance
Net Change in Excess Wages
Division of South Dakota.
Net Change in Taxable Wages
Keep one copy as part of your
Additional Contribution Due
9
records.
Reduction in Contribution
8
Adjustments
Interest/Penalty
7
Total Payment/Refund
Signature_________________________________________________________________________
Title__________________________________________________
Date_____________________________________
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