Form 21 - Employer'S Quarterly Contribution, Investment Fee And Wage Report

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EMPLOYER'S QUARTERLY CONTRIBUTION, INVESTMENT FEE AND WAGE REPORT
Form 21
South Dakota Department of Labor, Unemployment Insurance Division, Attention: Cashi
(rev. 9/10)
PO Box 4730 • Aberdeen, SD 57402-4730 • Phone 605.626.2312 • Fax 605.626.3347 •
Account Number
Instructions available in "Instructions" tab.
Business Name and Address
$0.00
3. Total gross wages paid in this quarter (Item 21)
$0.00
4. Wages paid this qtr in excess of annual per person (Item 22)
$0.00
5. Taxable wages (Item 3 minus Item 4)
$0.00
6. UI contribution rate
% x Line 5
0.0
$0.00
6a. Surcharge
% x Line 5
Quarter/Year
Due Date
/
$0.00
7. Investment fee rate
% x Line 5
$0.00
8. Total due (add lines 6, 6a & 7)
1. For each month, report the number of covered workers who worked during or received
pay for the payroll period which includes the 12th of the month.
9. Adjustment from prior quarters (explain on
"Line 14 & Line 9"
tab)
If none, enter "0"
$0.00
10. Interest: Line 8 x 1.5% per month from due date
%
1st month
2nd month
3rd month
11. Penalty for late filings: $5.00 per month
2. Does this account operate in more than one
12. Penalty for late payments: $5.00 per month
location in South Dakota?
Yes
No
$0.00
13. Total remittance (sum of Lines 8 through 12)
14. If your business in South Dakota has closed, ceased having employees, or
changed in ownership, please complete the
"Line 14 & Line 9"
worksheet. If
the ownership changed during this quarter, each owner must submit a report.
Make remittance payable to "South Dakota Unemployment Insurance Division"
15.
Employee's Social Security Number
16. Employee's Name (Last, First)
17. Total Gross Wages Paid This Quarter
18. Excess Wages Paid This Quarter
Signature
I certify all information on this report is complete and correct.
19. Total Gross Wages This Page
20. Total Excess Wages This Page
$0.00
$0.00
Title
Date
21. Total Gross Wages All Pages
22. Total Excess Wages All Pages
Prepared by
Telephone
$0.00
$0.00

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