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0773
V2
SD EForm -
Do Not Write in This Box - For SD DLR Office Use Only
Transfer ___________________ Into ____________________ Effective _______________ No Transfer
(rev. 7/14)
Unemployment Insurance Division
PO Box 4730, Aberdeen, SD 57402 • Phone 605.626.2312 • Fax 605.626.3347 •
Successor’s FEIN
Employer Account Number
-
1. Owner or Corporation
Phone
2. Business Name
3. Mailing Address
Address
City
State
Zip Code
(Note: Mailing address in #3 will receive all information including quarterly reports, debit/credit notices, rate notices, benefit charges, claim notices and appeals.)
4. Type of Organization: (Check One)
Individual
Partnership
Corporation
Association
LLC
LLP
Other Explain:
5. Work Locations
(Include new acquisition)
Indicate Specific Activity of Your Business
Zip Code
City
6. Acquired business by: (Check One)
Purchase
Merger
Receivership
Other
7. Date Acquired
Predecessor’s Account Number
8. Name of Predecessor
Address of Predecessor
Street
City
State
Zip Code
9. Did you acquire entire business, organization and assets?
Yes
No
If no, describe nature of assets and approximate percentage acquired
10. Number of employees on date of purchase
Number of employees as of this date
11. It was agreed between the
and the
that:
of the
Employer’s Experience Rating Account shall be acquired with assets and liabilities following the account, as provided in
Section 61-5-42 SDCL.
12. This report must be signed by an owner, an elected officer of the organization, a principal administrative officer, or a
responsible and duly authorized person having knowledge of the organization.
Signature___________________________________________Title___________
Print Name_________________________________________ Date__________
Registration
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