Sd Eform 0262 - 2007 Employer'S Report To Determine Liability Form - South Dakota Department Of Labor Page 2

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13. Have you paid wages for work performed in South Dakota?

Yes

If yes, give date of first employment in South Dakota.

If no, do you expect to pay wages in South Dakota in the future? Yes

If yes, estimate date.

Enter below your gross quarterly payrolls. Include all wages paid through the date that you complete this report. Do not estimate the amount of wages you expect

to pay in the future. Show wages for work performed primarily in South Dakota. Do not combine non-farm and agricultural wages. List wages separately for each

type of employment.

Year

QTR. JAN- MARCH

QTR APRIL-JUNE

QTR JULY-SEPT

QTR OCT-DEC

0.00

2007

0.00

2006

0.00

2005

14. In how many weeks have you had employees either full or part-time?

List below the number of individuals in your employ within each week. A month having five Saturdays is

considered as having five weeks of employment. Include all part-time employees and officers being remunerated by corporations. Do not complete this section for domestic employees. Do not combine non-farm and

agricultural employees. List employees separately for each type of employment.

Week

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sept

Oct

Nov

Dec

Current Year

2007

Week

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sept

Oct

Nov

Dec

Preceding Year

2006

15. Did you acquire any portion of an already established business?

Yes

15a. Name of business acquired.

Owner

15b. What was the date of the acquisition?

State account number.

FEIN

15c. It was agreed between you and the former owner that:

All

None

Portion

of the employer’s experience rating account

shall be acquired with the assets and liabilities following the account as provided in Section 61-5-33 SDCL.

16. BUSINESS ACTIVITY INFORMATION AND PHYSICAL LOCATION. If you have any questions regarding this section only (section 16), please call the

Labor Market Information Center at 1-800-592-1881 or 605-626-2314.

16a. Check the box that best describes your primary business activity.

Agricultural

Transportation

Public Administration

Other Services

Construction

Mining

Long Distance

Professional, Scientific,

Repair & Maintenance

Nonresidential Specialty

Utilities

Local

& Technical

Personal

Trade

Manufacturing

Information Services

Arts, Entertainment,

Member Organizations

Nonresidential Building

Wholesale Trade

Finance & Insurance

& Recreation

Private Households

Residential Specialty

Retail Trade

Real Estate / Rental & Leasing

Accommodations & Food

Trade

Other

Heavy & Civil

Engineering Services

16b. Indicate the specific activity of your business (i.e., fast food restaurant, house building).

See Attached Reference Guide

16c. List physical location\s in South Dakota. List street (not PO Box), city, zip code, and the # of workers for each location. Include: homes of

personnel when the company does not have an office or work-site in South Dakota.

Street Address

City

Zip Code

# of Employees in Each Location

17. Do you or will you have liability under the Federal Unemployment Tax Act or liability under another state’s unemployment laws in the current or

preceding calendar year.

Yes

Which year(s)?

18. Your signature indicates this report is true and complete to the best of your knowledge.

Signature

Title

Print name

Date

An unemployment account will not be established until you have met the liability requirements. If you do not currently have employees but indicate employment may

begin in the future, an additional inquiry may be made to determine your liability under the unemployment laws at a later date. You may also contact this office directly

to inform the department of a change in your employment status.

AFTER COMPLETING THIS FORM, PRINT USING BUTTON BELOW AND MAIL TO ADDRESS AT TOP OF THE FORM

OR FAX USING THE NUMBER PROVIDED

PRINT FOR MAILING

CLEAR FORM