Form 21c - Statement To Correct Information Previously Submitted
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1
2Form 21C (rev. 1/10)
Page 1
Statement to Correct Information Previously Submitted
South Dakota Department of Labor, Unemployment Insurance Division
PO Box 4730 • Aberdeen, South Dakota 57402-4730 • Phone 605.626.2312 • Fax 605.626.3347 • Web site:
1st Qtr 2009
2nd Qtr 2009
3rd Qtr 2009
4th Qtr 2009
Account Number
UI Rate
0.00
0.00
0.00
Company Name
Surcharge Rate
0.00
0.00
0.00
1.50
IF Rate
0.00
0.00
0.00
Year
2009
Total
0.00%
0.00%
0.00%
1.50%
A separate report is required for each year.
Amount Reported on Original Return
Correct Amount
Qtr/Yr to
Total Wages
Wages Paid in
Total Wages
Wages Paid in
Employee Name
Social Security #
be Corrected
Paid This Quarter
Excess of $9,500
Paid This Quarter
Excess of $9,500
/ 09
1
/ 09
2
/ 09
3
/ 09
4
/ 09
5
/ 09
6
/ 09
7
/ 09
8
Explanation:
Annual taxable wage base:
2006 & prior = $7,000
2009 = $9,500
2007 = $8,500
2010 = $10,000
2008 = $9,000
Quarter
Quarter
Quarter
Quarter
Make a copy of
office
3/31/09
6/30/09
9/30/09
12/31/09
Total
this report for your
coding
records. Send
Net Change in Total Wages
$0.00
$0.00
$0.00
$0.00
$0.00
original to the
Net Change in Excess Wages
$0.00
$0.00
$0.00
$0.00
$0.00
Unemployment
Insurance Division
Net Change in Taxable Wages
$0.00
$0.00
$0.00
$0.00
$0.00
of South Dakota.
Additional Contribution Due
9
$0.00
Reduction in Contribution
8
$0.00
Adjustments
$0.00
Interest/Penalty
7
$0.00
Total Payment/Refund
$0.00
$0.00
$0.00
$0.00
$0.00
I certify that this report is correct and no part of the contribution was or will be paid by any employee.
Signature
Title
Date
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