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Form 1 - Employer'S Report To Determine Liability - South Dakota Department Of Labor And Regulation

EMPLOYER’S REPORT TO DETERMINE LIABILITY

Form 1

(rev. 7/12)

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 •

This report must be completed whether or not you are liable for contributions under the South Dakota Unemployment Insurance Laws. Completion will

help determine if you must pay state unemployment insurance taxes. Return this report within 10 days unless you receive different instructions. If you

have no employees, answer only Questions 1 through 13, sign the form on the back and return it to the above address.

1. Enter your FEIN

Do Not Write in This Box – For SD DLR Office Use Only

NAICS Code

Account Number

2. Phone Number (

)

Cell

C – Number

Employer Liability

2a. Fax Number (

)

Begins

2b. Name of Contact Person

Liability Code

Applicable Rate

3. Email Address

Date

Rates

Territory

Reviewer’s Initials

Date

4. Owner or Corporation Name

P-number

Account Code

5. Business Name or DBA

6. Mailing Address

7. Business Headquarters Address

8. Type of Ownership

1. Individual

( )

2. Partnership ( )

3. Corporation ( )

4. Association ( )

(Check One)

5. LLC ( )

If LLC, what type of Federal Income Tax Return is filed with the IRS? 1040 ( )

1065 ( )

1120 ( )

6. Other ( )

Explain:

State of Incorporation:

Date of Incorporation:

Identification of Owner, Partners, Corporate Officers, Members, etc.

Social Security Number

Name

Title

% of Ownership

Residential Address

10. For Corporations Only

10a. Are you a non-profit organization as described in section 501(c)(3) of the IRS Code?

Yes ( )

No ( )

If yes, you must submit a copy of the IRS determination letter.

10b. Have the officers received any remuneration, including dividends or other disbursements?

Yes ( )

No ( )

11. Have you previously reported to the SD Unemployment Insurance Division? Yes ( ) No ( ) If yes, enter the account number:

12. If you have or had any individuals performing services for you in South Dakota who you consider to be independent contractors or

subcontractors and not your employees, attach a separate sheet of paper listing their name, business name, address, telephone number, type

of business activity and FEIN/SSN.

12a. Do you pay any individuals for day labor, casual labor, or cash?

Yes ( )

No ( )

Please complete additional questions on back of form and sign.

Registration

Form 1 - Employer'S Report To Determine Liability - South Dakota Department Of Labor And Regulation

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