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Form Dol-Uid-21 - Employer'S Quarterly Contribution, Investment Fee, And Wage Report - 1999 Page 3

EMPLOYER’S QUARTERLY CONTRIBUTION, INVESTMENT FEE, AND WAGE REPORT

Unemployment Insurance Division of South Dakota

ITEM 14

IMPORTANT: IF YOUR BUSINESS IN SOUTH DAKOTA HAS CHANGED IN ANY WAY, PLEASE COMPLETE

ITEMS A OR B BELOW.

A. If business was discontinued without a successor; give date of last employment________________________________________

I hereby make application for exemption from filing all reports required under the Unemployment Insurance Law. I agree to advise

the Unemployment Insurance Division at any date in the future that I should again enter business and employ persons.

B. If the business was sold, leased, or otherwise transferred, complete the following:

Name and address of successor________________________________________________________________________________

________________________________________________________________________

Effective date of disposition__________________________________________________________________________________

Are you retaining any part of the business: Yes_____ No_____

Number of employees retained________________________________________________________________________________

The Unemployment Insurance Division is hereby authorized to transfer All_____ None_____ of the experience rating account

under the number shown on the face of this report to the above referenced successor.

Signed (By owner or officer)

Title

Date

ITEM 9

Quarter Ending____________________________________________________________________________________________

Explanation of Adjustment:

______________________________________________________________________

Form Dol-Uid-21 - Employer'S Quarterly Contribution, Investment Fee, And Wage Report - 1999 Page 3