Form Dol-Uid-1np - Registration Report To Determine Liability For Nonprofit Organizations
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DOL-UID-1NP (Rev 10/92)
UNEMPLOYMENT INSURANCE DIVISION OF SOUTH DAKOTA
BOX 4730
ABERDEEN, SOUTH DAKOTA 57402-4730
SD EForm - 0763
V1
DO NOT WRITE IN THIS SPACE
REGISTRATION REPORT TO DETERMINE
LIABILITY FOR NONPROFIT ORGANIZATIONS
REGISTRATION NUMBER
C.
Employer Liability
Begins
This report is to be completed whether or not you are liable for contributions under the South
Dakota Unemployment Insurance Law, and returned to the Division within ten (10) days.
No. 21a
Applicable Rate:
Reviewer's Initials:
TYPE OF ELECTION:
CONTRIBUTION
REIMBURSEMENT
Enter your Federal Identification Number:________________________________________
PERCENTAGE
BOND REQUIRED
YES
NO
1. OWNERSHIP __________________________________________________________________________________________________________
BUSINESS NAME ___________________________________________________
PHONE
___________________________________
(Area Code)
2. MAIL ADDRESS _______________________________________________________________________________________________________
(Street Address or Box # )
(City)
(State)
(Zip Code)
BUS HEADQTRS ADDR _________________________________________________________________________________________________
(Street Address or Box # )
(City)
(State)
(Zip Code)
3. TYPE OF ORGANIZATION: (Check One)
1. Corporation
2. Association
3. Other
Explain ________________
IF A CORPORATION, complete the following questions:
State of Incorporation __________
Date of Incorporation
________
Date Qualified in S.D. _______________
Name of Statutory Agent ____________________________________ Address ______________________________________________________
4. IDENTIFICATION OF PRINCIPAL ADMINISTRATIVE OFFICERS
SOCIAL SECURITY NUMBER
NAME (Given name must be shown in full)
TITLE
RESIDENCE ADDRESS
NATURE OF BUSINESS
5. WORK LOCATIONS (List Additional Locations in Comment Section)
City
County
Primary Activity
Principal Product/Service
(a)
(b)
6. WEEKLY RECORD OF EMPLOYMENT:
Enter the number of individuals performing services for you in the day in which you employed the largest number
within each calendar week ending at midnight Saturday (For instructions of completion of item 8, see next page)
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
WEEKS IN
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
WEEKS IN
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
7.
SHOULD OUR EMPLOYING UNIT BE AN EMPLOYER, WE HEREBY ELECT THE FOLOWING METHOD OF PAYMENT: (Check one)
(See next page for information on elections.)
TO PAY CONTRIBUTIONS AS AN EMPLOYER AS PROVIDED IN CHAPTER 61-5 SDCL.
ELECT REIMBURSEMENT OF BENEFITS IN LIEU OF CONTRIBUTIONS AS PROVIDED IN CHAPTER 61-5A-6 SDCL.
PERIODIC BILLING FOR PAYMENT IN LIEu OF CONTRIBUTIONS BASED ON PAYROLL AS PROVIDED IN CHAPTER 61-5A-28 SDCL.
SIGNATURES: THIS REPORT MUST BE SIGNED BY AN ELECTED OFFICER OF THE ORGANIZATION, A PRINCIPAL ADMINISTRATIVE
8.
OFFICER, OR A RESPONSIBLE AND DULY AUTHORIZED MEMBER HAVING KNOWLEDGE OF THE ORGANIZATION.
I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THIS REPORT IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF.
DATE__________________________ BY (SIGNATURE)_____________________________________________________
TITLE___________________________________
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