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SD EForm -
Unemployment Insurance Division
PO Box 4730, Aberdeen, SD 57402 • Phone 605.626.2312 • Fax 605.626.3347 •
Employer Account Number
1. Owner or Corporation
2. Business Name
3. Present Mailing Address
4. Type of Organization: (Check One)
5. Work Locations
(Include new acquisition)
Indicate Specific Activity of Your Business
6. Acquired business by: (Check One)
7. Date Acquired
Predecessor’s Account Number
8. Name of Predecessor
Address of Predecessor
9. Did you acquire entire business, organization and assets?
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
Employer’s Experience Rating Account shall be acquired with assets and liabilities following the account, as provided in
Section 61-5-42 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 ________________
Print Name_________________________________________ Date__________
Print Name_____________________________________________Date ________________
Do not write in this space—SD DLR use only
Transfer effective __________________________
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