Form Dlr-Uid-222 - The Audit Of Wages And Benefits Paid

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NAME
SD DEPARTMENT OF LABOR AND REGULATION
UNEMPLOYMENT INSURANCE DIVISION
SOCIAL SECURITY NO.
420 SOUTH ROOSEVELT
EMPLOYER ACCOUNT NO.
ABERDEEN, SD 57402-4730
(605) 626-7649
QUARTER
YEAR
WAGES TOTALING $
Your firm paid wages to the individual on the right during the quarter
indicated. Please fill in the information for the weeks listed below
1. DATE EMPLOYED______/______/______
(instructions are on reverse). Please sign at the bottom and return
2. DATE TERMINATED______/______/______
form in the enclosed envelope. This form does not indicate that
3. STILL EMPLOYED?  Yes
 No
your account was or was not charged for benefits. A separate
4. PAY RATE: $______________________
notice is mailed to notify you when a claim is filed.
5. INDICATE PAY PERIOD:
 MONTHLY – ENTER PAY DATE
 SEMI-MONTHLY – ENTER DATES
 WEEKLY – CIRCLE PAY DATES: S M T W T F S
 BI-WEEKLY – CIRCLE PAY DATE: S M T W T F S
KEY FOR #11: W-REGULAR WAGE
S-SEVERANCE
V-VACATION
H-HOLIDAY
O-OTHER
 
6.
CHECK IF NO WORK PERFORMED IN WEEKS LISTED BELOW
7. CIRCLE DAYS WORKED IN WEEKS BELOW.
8. HRS
9. GROSS
10. DATE
11. PAY TYPE, SEE KEY ABOVE
Month Sun
Mon
Tues
Wed
Thur
Fri
Sat
Month
WKD
WAGES
PAID
W
S
V
H
O
I CERTIFY THAT THE INFORMATION PROVIDED ON THIS FORM IS CORRECT.
Signature_____________________________________ Title_____________________________Date__________________Phone___________________
DLR-UID-222 (7-11) AUDIT OF WAGES & BENEFITS PAID

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