Form 1 - Employer'S Report To Determine Liability - South Dakota Department Of Labor And Regulation Page 2
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213. Have you paid wages for work performed in South Dakota? Yes
If yes, give date of first employment in South Dakota.
No
13a. If no, do you expect to pay wages in South Dakota in the future? Yes
No
If yes, estimate date.
13b. Enter below your gross quarterly payrolls. Include all wages for work performed primarily in South Dakota, paid through today’s date.
Do not included wages you expect to pay in the future. List agricultural and non-agricultural wages separately.
st
nd
rd
th
Year
1
Qtr Jan. - March
2
Qtr April - June
3
Qtr July – Sept.
4
Qtr Oct. – Dec.
Current
Preceding
Preceding
14. In how many weeks have you had employees either full or part-time? List below the number of individuals in your employ within each week.
A month having five Saturdays is considered as having five weeks of employment. Include all part-time employees and officers being remunerated
by corporations. Do not include domestic employees. List agricultural and non-agricultural employees separately.
Week
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
1
Current Year
2
3
4
5
Week
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Preceding Year
1
2
3
4
5
15. Did you acquire any portion of an already established business?
If yes, please complete 15a, 15b, 15c.
Yes
No
15a. Name of business acquired.
Owner
15b. Date of the acquisition?
SD UI account number
FEIN
15c. It was agreed between you and the former owner that: All
None
Portion
of the employer’s experience rating account
shall be acquired with the assets and liabilities following the account as provided in Section 61-5-42 SDCL.
16.
Business Activity Information and Physical Location
If you have any questions regarding this section only, please call the Labor Market Information Center at 1-800-592-1881 or 605-626-2314.
16a. Check the box that best describes your primary business activity.
Agricultural
Transportation
Professional, Scientific,
Management of Companies
Construction
Mining
Long Distance
& Technical Services
& Enterprises
Residential Building Construction
Utilities
Local
Health Care & Social Assistance
Administrative, Support, Waste
Nonresidential Building Construction
Manufacturing
Information Services
Arts, Entertainment,
Management & Remediation Services
Specialty Trade Contractors
Wholesale Trade
Finance & Insurance
& Recreation
Educational Services
Heavy & Civil Engineering
Retail Trade
Real Estate, Rental & Leasing
Accommodations & Food
Public Administration
Construction
Other Services
16b. Indicate the specific activity of your business (e.g. fast food restaurant, house building).
16c. List physical location(s) in South Dakota. List street (not PO Box), city, ZIP code, and the number of workers for each location. Include home
addresses of personnel when the company does not have an office or work-site in South Dakota.
Street Address
City
ZIP Code
Number of Employees in Each Location
17. Do you or will you have liability under the Federal Unemployment Tax Act or liability under another state’s unemployment laws in the
current or preceding calendar year?
If yes, which year(s)?
Yes
No
18. Your signature indicates this report is true and complete to the best of your knowledge.
Signature
Title
Print name
Date
An unemployment account will not be established until you have met the liability requirements. If you do not currently have employees but
indicate employment may begin in the future, an additional inquiry may be made to determine your liability under the unemployment laws at a
later date. You may also contact this office directly to inform the department of a change in your employment status.
AFTER COMPLETING THIS FORM, PRINT USING BUTTON BELOW AND MAIL TO ADDRESS AT TOP OF THE FORM
PRINT FOR MAILING
CLEAR FORM
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