Form 0762 - Employer'S Report To Determine Liability

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SD EForm -
0762
V4
HELP
EMPLOYER’S REPORT TO DETERMINE LIABILITY
Form 1
(rev. 12/08)
South Dakota Department of Labor
Unemployment Insurance Division
PO Box 4730, Aberdeen, SD 57402-4730 • Phone (605) 626-2312 • Fax (605) 626-3347 •
This report must 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, answer only Questions 1 through 13, sign the form on the back and return it to the above address.
-
1. Enter your FEIN
Do Not Write in This Box – For SD DOL Office Use Only
Account Number
Cell
2. Phone Number
C – Number
Employer Liability
2a. Fax Number
Begins
2b. Name of Contact Person
Liability Code
Applicable Rate
UI
3. E-mail Address
Date
Rates
IF
Territory
Reviewer’s Initials
Date
4. Owner or Corporation Name
P-number
Account Code
N
P
5. Business Name or DBA
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 described in section 501(c) 3 of the IRS Code?
Yes
No
If yes, you must submit a copy of the IRS determination letter.
10b. Have the officers received any remuneration, including dividends or other disbursements?
Yes
No
11. Have you previously reported to the SD 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, or cash?
Yes
No
Please complete additional questions on second page of form and sign.

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