Form 1ps - Registration Report To Determine Liability For Political Subdivision

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SD EForm -
0764
V2
Complete and use the button at the end to print for mailing.
HELP
REGISTRATION REPORT TO DETERMINE LIABILITY
Form 1PS
(rev. 4/11)
FOR POLITICAL SUBDIVISION
South Dakota Department of Labor and Regulation
Unemployment Insurance Division
PO Box 4730, Aberdeen, SD 57402 • 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 Law, and
returned to the Division within 10 days.
Do Not Write In This Space – SD DLR Use Only
-
1. Enter your Federal Identification Number:
NAICS Code
Account Number
Account Number:
C-number
Employer
Liability Begins
2. Phone Number
Cell
Liability Code
Applicable
UI
Fax Number
Rates
IF
& Date
Territory
Reviewer
Contact Person(s)
Date
Account Code
N
P
P-Number
Email Address
Type of Election
Bond
3. Owner or Corporate Name
Contribution
Reimbursement
Percentage
Yes
No
4. Business Name
5. Mail Address
(Address)
(City)
(State)
(Zip Code)
6. Business Headquarters Address
(Street Address)
(City)
(State)
(Zip Code)
Type Of Organization: (Check One)
1. City
2. County
3. Township
4. School District
Other
7. Identification Of Principal Administrative Officers:
Social Security Number
Name
Title
Residence Address
8. Work Locations:
Nature of Business
(List additional locations In Comment Section)
Street Address
City
Primary Activity
Principal Service
(A)
(B)
9. Date of First Employment in South Dakota:
10. We elect the following method of payment: (check one) (see reverse for information on available options.)
To pay contributions as an employer as provided in chapter 61-5 SDCL.
Elect reimbursement of benefits in lieu of contributions as provided in chapter 61-5a-6 SDCL.
Periodic billing for payment in lieu of contributions based on payroll as provided in chapter 61-5a-28 SDCL.
12. Signature
:
This report must be signed by an elected officer of the organization, a principal administrative officer, or a responsible and duly authorized
person having knowledge of the organization.
I hereby certify that the information contained in this report is true and correct to the best of
my knowledge, information and belief.
Signature ______________________________________________Title__________________________
Print Name _____________________________________________ Date_________________________
Registration

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