Form 21c - Statement To Correct Information Previously Submitted - 2012
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2Form 21C (rev. 4/12)
Statement to Correct Information Previously Submitted
South Dakota Department of Labor and Regulation, Unemployment Insurance Division
PO Box 4730 • Aberdeen, SD 57402-4730 • Phone 605.626.2312 • Fax 605.626.3347 •
Account Number
UI Rate
%
Employer
Year
IF Rate
%
Address
Q1
Q2
Q3
Q4
A separate report is required for each year.
Surcharge Rate
____%
_____% ____% ____%
Amount Reported on Original Report
Correct Amount
Qtr/Yr to
Total Wages
Wages Paid in
Total Wages
Wages Paid in
Employee Name
Social Security #
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:
2009 = $9,500
2013 = $13,000
2010 = $10,000
2014 = $14,000
2011 = $11,000
2015 & later = $15,000
2012 = $12,000
Quarter
Quarter
Quarter
Quarter
office
Make a copy of
3/31/____
6/30/____
9/30/____
12/31/____
Total
coding
this report for your
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
7
(1.5% per month from due date)
Penalty
7
Total Payment/Refund
I certify all information on this report is complete and correct.
Signature
Title
Date
Phone
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