Form 21c - Statement To Correct Information Previously Submitted
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1
2Form 21C (rev. 3/07)
Statement to Correct Information Previously Submitted
South Dakota Department of Labor, Unemployment Insurance Division
P.O. Box 4730 Aberdeen, South Dakota 57402-4730 Phone 605-626-2312 Fax 605-626-3347
UI Rate
Name
Account Number
IF Rate
Address
Year
2007
Total
Amount Reported on Original Return
Correct Amount
Qtr/Yr to
Total Wages
Wages Paid In
Total Wages
Wages Paid In
Social Security #
Employee Name
be Corrected
Paid This Quarter
Excess of $8,500
Paid This Quarter
Excess of $8,500
/ 07
1
/ 07
2
/ 07
3
/ 07
4
/ 07
5
/ 07
6
/ 07
7
/ 07
8
Explanation:
Separate Report is
Quarter
Quarter
Quarter
Quarter
I certify that this
report is correct and
Required for Each Year
Code
3/31/07
6/30/07
9/30/07
12/31/07
Total
no part of the
Net Change in Total Wages
contribution was or
will be paid by any
Net Change in Excess Wages
employee. Send
Net Change in Taxable Wages
original to the
Unemployment
Additional Contribution Due
9
Insurance Division of
Reduction in Contribution
8
South Dakota. Keep
one copy as part of
Adjustments
your records.
Interest/Penalty
7
Total Payment/Refund
Signature
Title
Date
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