Form 21c - Statement To Correct Information Previously Submitted Page 2
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2Form 21Cc (rev. 4/10)
Statement to Correct Information Previously Submitted
South Dakota Department of Labor, Unemployment Insurance Division
PO Box 4730 • Aberdeen, SD 57402-4730 • Phone 605.626.2312 • Fax 605.626.3347 • Website:
Account Number
Employer
Year
Amount Reported on Original Return
Correct Amount
Qtr/Yr to
Total Wages
Wages Paid in
Total Wages
Wages Paid in
Social Security #
Employee Name
be Corrected
Paid This Quarter
Excess of $_________
Paid This Quarter
Excess of $_________
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