Form 55 - Application For Exemption Or Transfer Of Liability
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SD EForm - 0774 V4
HELP
Form 55
(rev. 4/14)
APPLICATION FOR EXEMPTION OR TRANSFER OF LIABILITY
South Dakota Department of Labor and Regulation
Unemployment Insurance Division
PO Box 4730, Aberdeen, SD 57402-4730 • Phone 605.626.2312 • Fax 605.626.3347 •
1. Account Number
Owner or Corporate Name
Business Name or DBA
Mailing Address
State
Zip
Address
City
(Note: mailing address above will receive all information including debit/credit notices, benefit charges, claim notices and appeals.)
I hereby make application for exemption from filing all reports required under the unemployment insurance law of
2.
South Dakota. I agree to advise SD Unemployment Insurance Division if I have employment again at any time in the
future.
If employment ceased or business was discontinued without a successor, give last date wages were paid
or
If business was sold, leased or otherwise transferred, please complete the following:
Effective date of disposition
Date you last paid wages in South Dakota
Are you retaining any part of the business?
Yes
No
Disposed of the business by:
Sale
Merger
Receivership
LLP
LLC
Incorporation
Dissolution
Partnership
Other
3. Name of successor
Phone
Address of successor
Address
City
State
Zip
Type of organization: (Check one)
Individual
Corporation
LLP
LLC
Partnership
Association
Other
4. It is agreed between the Former Owner and the New Owner that:
All
None
Portion
of the
Employer’s Experience Rating Account shall be transferred with assets and liabilities following the account, as
provided in Section 61-5-42 SDCL.
5. This report must be signed by the owner, partner or authorized official.
Signature ______________________________ Title _______________ Phone ____________ Date _______________
For SD DLR use only:
Approved date ________________________ By _________________
Effective date ________________________
Termination date ______________________
Registration
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