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SD EForm -
0762
V2
HELP
FORM 1 - 2007 EMPLOYER’S REPORT TO DETERMINE LIABILITY
South Dakota Department of Labor
Unemployment Insurance Division
PO Box 4730•Aberdeen SD, 57402-4730•Phone (605)626-2312•Fax (605)626-3347•Website:
1. Enter your FEIN
-
Do Not Write in This Box – For Central Office Use Only
Account Number
2. Phone Number
Ext
(Area Code)
C – Number
Employer Liability
2a. Fax Number
Begins
(Area Code)
2b. Name of Contact Person
No. 21a
Applicable Rate UI
IF
3. E-mail Address
Liability Code
Reviewers
& Date
Initials
FR Territory
Account Code
N
P
4. OWNERS
5. BUSINESS NAME
6. MAILING ADDRESS
7. BUSINESS HEADQUARTERS ADDRESS
8. TYPE OF OWNERSHIP
1. Individual
2. Partnership
3. Corporation
4. Association
(Check One)
5. LLC
If LLC, what type of Federal Income Tax Return is filed with the IRS?
1040
1065
1120
6. Other
Explain:
State of Incorporation :
Date of Incorporation:
9.
IDENTIFICATION OF OWNER, PARTNERS, CORPORATE OFFICERS, MEMBERS, Etc.
Social Security Number
Name
Title
% of Ownership
Address
10. FOR CORPORATIONS ONLY
10a. Are you a non-profit organization as describe in section 501(c) 3 of the IRS Code?
Yes
No
If yes, you must submit a copy of the IRS determination letter of your status.
10b. If your business is a corporation, have the officers received any remuneration (including dividends and other disbursements)?
Yes
No
11. Have you previously made a report to the Unemployment Insurance Division?
Yes
No
If yes enter the account number:
12. If you have or had any individuals performing services for you in South Dakota who you consider to be independent contractors or subcontractors and not
your employees, attach a separate sheet of paper listing their name, business name, address, telephone number, type of business activity and FEIN\SS number.
12a. Do you pay any individuals for day labor, casual labor, rent-a-kid or cash?
Yes
No
This report is to be completed whether or not you are liable for contributions under the South Dakota Unemployment Insurance Laws. Completion will help determine
if you must pay state unemployment insurance taxes. Return this report within 10 days unless you receive different instructions. If you have no employees only answer
questions 1-13b, sign, and return.
Please complete additional questions on back of form and sign.