Form Dol-Uid-21 - Employer'S Quarterly Contribution, Investment Fee, And Wage Report - 1999
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3EMPLOYER’S QUARTERLY CONTRIBUTION, INVESTMENT FEE, AND WAGE REPORT
Unemployment Insurance Division of South Dakota
DOL-UID-21 (9/99)
P.O. Box 4730 • Aberdeen, South Dakota 57402-4730 • Phone (605) 626-2312
EXAMPLE: TYPE characters THROUGH boxes
Account Number
Please use Black Ink Only.
Completion instructions are on the back of
EXAMPLE: PRINT characters IN boxes
the employer copy and below.
3. Total gross wages paid in this quarter (Item 21)
4. Wages in excess of the annual $8,500 paid this quarter (Item 22)
5. Taxable wages (Item 3 minus Item 4)
6. UI contribution rate
% x line 5
Quarter/Year
Due Date
7. Investment fee rate
% x line 5
8. Total due (add lines 6 & 7)
9. Adjustment from prior quarters (explain on reverse or attachment)
1.
For each month, report the number of covered workers who worked during or
received pay for the payroll period which includes the 12th of the month.
10. Interest: Line 8 x 1.5% per month from due date
If none, enter “0”
11. Penalty for late filings: $5.00 per month
1st month
2nd month
3rd month
12. Penalty for late payments: $5.00 per month
2.
Does this account operate in more than
13. Total remittance (Add lines 8, 9, 10, 11 & 12)
one location in South Dakota?
Yes
No
14. If your business in South Dakota has changed in any way, please complete Item 14 on the back side of this
Make remittance payable to the South Dakota
14. If your business in South Dakota has changed in any way, please complete Item 14 on the back side of this
page. If the ownership changed during this quarter, a separate report must be submitted by each ownership.
Unemployment Insurance Division
page. If the ownership changed during this quarter, a separate report must be submitted by each ownership.
15. Employee’s Social Security Number
16. Employee’s Name (Last, First)
17. Total Gross Wages Paid This Quarter
18. Excess Wages This Quarter
I certify all information on this report is complete and correct.
19. Total Gross Wages This Page
20. Total Excess Wages This Page
Signature
Title
Date
21. Total Gross Wages All Pages
22. Total Excess Wages All Pages
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