Form 21 - Annual Taxable Wage Base Per Employee - South Dakota printable pdf download

Form 21 - Annual Taxable Wage Base Per Employee - South Dakota

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.

Account Number

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

Quarter/Year

Due Date

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

1st month

2nd month

3rd month

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?

Yes

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”

side

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your check to make an EFT, funds may be withdrawn from your account as soon as the same day we receive your payment.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

Signature

I certify all information on this report is complete and correct.

19. Total Gross Wages This Page

20. Total Excess Wages This Page

Title

Date

21. Total Gross Wages All Pages

22. Total Excess Wages All Pages