Form 21 - Employer'S Quarterly Contribution, Investment Fee, And Wage Report
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3EMPLOYER’S QUARTERLY CONTRIBUTION, INVESTMENT FEE, AND WAGE REPORT
South Dakota Department of Labor, Unemployment Insurance Division
Form21 (3/08)
P.O. Box 4730 • Aberdeen, South Dakota 57402-4730 • Phone (605) 626-2312 • Web site
EXAMPLE: TYPE characters THROUGH boxes
Account Number
Machine print
Please use Black Ink Only.
Completion instructions are on page three below.
EXAMPLE: PRINT characters IN boxes
H a n d
p r i n t
Annual Taxable Wage base, per employee:
2006 & prior - $7,000, 2007 - $8,500
2008 - $9,000, 2009 - $9,500, 2010 - $10,000
3. Total gross wages paid in this quarter (Item 21)
4. Wages in excess of annual taxable wage base. (Item 22)
5. Taxable wages (Item 3 minus Item 4)
6. UI contribution rate
% x line 5
Quarter/Year
Due Date
7. Investment fee rate
% x line 5
8. Total due (add lines 6 & 7)
1.
For each month, report the number of covered workers who worked during or
9. Adjustment from prior quarters (explain on page 2 or attachment)
received pay for the payroll period which includes the 12th of the month.
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 filings: $5.00 per month
12. Penalty for late payments: $5.00 per month
2.
Does this account operate in more than
one location in South Dakota?
Yes
No
13. Total remittance (Add lines 8, 9, 10, 11 & 12)
Make remittance payable to the “South Dakota
14. If your business in South Dakota has changed in any way, please complete Item 14 on the back side of this
14. If your business in South Dakota has changed in any way, please complete Item 14 on the back side of this
Unemployment Insurance Division”
page. If the ownership changed during this quarter, a separate report must be submitted by each ownership.
page. If the ownership changed during this quarter, a separate report must be submitted by each ownership.
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.
Signature
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
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