Form 21c - Statement To Correct Information Previously Submitted
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1
2Form 21C (rev. 3/08)
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 • Web site:
UI Rate
Name
Account Number
IF Rate
Address
Year
Total
A separate report is required for each year.
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 $_______
Paid This Quarter
Excess of $_______
/
1
/
2
/
3
/
4
/
5
/
6
/
7
/
8
Explanation:
Annual taxable wage base:
2006 & prior = $7,000
2009 = $9,500
2007 = $8,500
2010 = $10,000
2008 = $9,000
Separate Report is
Quarter
Quarter
Quarter
Quarter
Make a copy of
office
Required for Each Year
3/31/
6/30/
9/30/
12/31/
Total
this report for your
coding
records. Send
Net Change in Total Wages
original to the
Net Change in Excess Wages
Unemployment
Insurance Division
Net Change in Taxable Wages
of South Dakota.
Additional Contribution Due
9
Reduction in Contribution
8
Adjustments
Interest/Penalty
7
Total Payment/Refund
I certify that this report is correct and no part of the contribution was or will be paid by any employee.
Signature
Title
Date
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