Form 21 - Employer'S Quarterly Contribution, Investment Fee And Wage Report (Page 3 of 3) in pdf

Form 21 - Employer'S Quarterly Contribution, Investment Fee And Wage Report Page 3

EMPLOYER’S QUARTERLY CONTRIBUTION, INVESTMENT FEE AND WAGE REPORT

Unemployment Insurance Division

Line 14

IMPORTANT: If your business in South Dakota has closed, no longer has employees, or has had a change

in ownership, please complete items A or B below.

A. If business was discontinued without a successor, or the business continues without employees,

please give date of last employment

I hereby make application for exemption from filing all reports required under the Unemployment Insurance Law. I agree

to advise the Unemployment Insurance Division at any date in the future if I again enter business and employ persons.

If the business was sold, leased or otherwise transferred, complete the following:

Name and address of successor

Effective date of disposition

Are you retaining any part of the business?

Yes

Number of employees retained

The Unemployment Insurance Division is hereby authorized to transfer

ALL

NONE

PORTION

of the experience rating account under the number shown on the face of this report to the referenced successor.

Signed

(By owner or officer)

Title

Date

Name

)

(print

Line 9

Quarter Ending

Explanation of Adjustment:

Form 21 - Employer'S Quarterly Contribution, Investment Fee And Wage Report Page 3