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SD EForm - 0762 V4
EMPLOYER’S REPORT TO DETERMINE LIABILITY
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
2. Phone Number
C – Number
2a. Fax Number
2b. Name of Contact Person
3. Email Address
4. Owner or Corporation Name
5. Business Name or DBA
6. Mailing Address
7. Business Headquarters Address
8. Type of Ownership
If LLC, what type of Federal Income Tax Return is filed with the IRS? 1040
State of Incorporation:
Date of Incorporation:
Identification of Owner, Partners, Corporate Officers, Members, etc.
Social Security Number
% of Ownership
10. For Corporations Only
10a. Are you a non-profit organization as described in section 501(c)(3) of the IRS Code?
If yes, you must submit a copy of the IRS determination letter.
10b. Have the officers received any remuneration, including dividends or other disbursements?
11. Have you previously reported to the SD Unemployment Insurance Division? Yes
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?
Please complete additional questions on second page of form and sign.