EMPLOYER’S QUARTERLY CONTRIBUTION, INVESTMENT FEE, AND WAGE REPORT
Form 21 (rev. 7/16)
South Dakota Department of Labor and Regulation, Unemployment Insurance Division, Attention: Cashier
PO Box 4730, Aberdeen, SD 57402-4730 • Phone 605.626.2312 • Fax 605.626.3347 •
Please use Black Ink Only.
Completion instructions are on page four below.
Annual Taxable Wage base, per employee:
2011=$11,000, 2012=$12,000, 2013=$13,000, 2014=$14,000, 2015 & after=$15,000
3. Total gross wages paid in this quarter (Item 21)
4. Wages paid this quarter in excess of annual per person (Item 22)
5. Taxable wages (Item 3 minus Item 4)
6. UI contribution rate
% x line 5
6a. Surcharge rate
% x line 5
7. Investment fee rate
% x line 5
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 attached page )
If none, enter “0”
10. Interest: Line 8 x 1.5% per month from due date
11. Penalty for late filing: $25.00 per month
12. Penalty for late payment: $25.00 per month
2. Does this account operate in more than one
location in South Dakota?
13. Total remittance (add lines 8, 9, 10, 11 & 12)
14. If your business in South Dakota has changed in any way, please complete Item 14 on
14. If your business in South Dakota has changed in any way, please complete Item 14 on the back
following page. If the ownership changed during this quarter, each owner must submit a report.
Make remittance payable to “SD Unemployment Insurance”
Note: When you make a check payment, you authorize us to use information from your check to make a one-time electronic funds transfer (EFT) from your account. When we use information from
your check to make an EFT, funds may be withdrawn from your account as soon as the same day we receive your payment. You will not receive your check back from your financial institution.
15. Employee’s Social Security Number
16. Employee’s Name (Last, First)
17. Total Gross Wages Paid This Quarter
18. Excess Wages This Quarter
I certify all information on this report is complete and correct.
19. Total Gross Wages This Page
20. Total Excess Wages This Page
21. Total Gross Wages All Pages
22. Total Excess Wages All Pages