Form 55 - Application For Exemption Or Transfer Of Liability printable pdf download

Form 55 - Application For Exemption Or Transfer Of Liability

Form 55 (Revised 9-99)

APPLICATION FOR EXEMPTION OR TRANSFER OF LIABILITY

UNEMPLOYMENT INSURANCE DIVISION OF SOUTH DAKOTA, PO BOX 4730, ABERDEEN, SD 57402-4730

1. Account Number

Owner(s)

Business Name

Mail Address

Street

City

State

Zip

We/I hereby make application to the UNEMPLOYMENT INSURANCE DIVISION OF SOUTH DAKOTA for exemption

from filing all reports required under the UNEMPLOMENT INSURANCE LAW OF SOUTH DAKOTA or Regulations made in

pursuance thereof for the following reason:

If employment ceased or the business was discontinued without a successor; give last date of employment.

Effective date of disposition

The date you last paid wages in South Dakota

If the business was sold, leased, or otherwise transferred, complete the following:

Disposed business by:

( ) Sale

( ) Merger

( ) Receivership

( ) LLP

( ) Dissolution

( ) Partnership

( ) Incorporation

( ) LLC

( ) Other

3. Name of successor

Address of successor

Type of organization: (Check One)

( ) Individual

( ) Corporation

( ) LLC

( ) Partnership

( ) Association

( ) LLP

( ) Other:

4. It was agreed between the FORMER OWNER and NEW EMPLOYER that: All ( )

None ( )

Portion ( ) of the

Employer’s Experience Rating Account shall be transferred with assets and liabilities following the account as provided in Section

61-5-33 SDCL.

5. THIS REPORT MUST BE SIGNED BY THE OWNER, PARTNER, OR AUTHORIZED OFFICIAL.

Date

Signature

Title

For Unemployment Insurance Division use only:

Approved on this

day of

Effective Date

Termination would be effective

Form 55 - Application For Exemption Or Transfer Of Liability

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