Sd Eform-0773 V2 - Employer'S Report On Acquiring A Business
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10773
V2
HELP
SD EForm -
Complete and use the button at the end to print for mailing.
(rev. 4/11)
Form 49
EMPLOYER’S REPORT ON ACQUIRING A BUSINESS
South Dakota Department of Labor and Regulation
South Dakota Department of Labor
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. Present Mailing Address
Street
City
State
Zip Code
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 Successor and the Predecessor that: All
None
Portion
of the
Employer’s Experience Rating Account shall be acquired with assets and liabilities following the account, as provided in
Section 61-5-33 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___________
Signature ______________________________________________ Title ________________
Print Name_________________________________________ Date__________
Print Name_____________________________________________Date ________________
Do not write in this space—SD DLR use only
Transfer effective __________________________
No Transfer
__________________________
Registration
PRINT FOR MAILING
CLEAR FORM
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