Form 21 - Employer'S Quarterly Contribution, Investment Fee, And Wage Report Page 2

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UNEMPLOYMENT INSURANCE DIVISION OF SOUTH DAKOTA
DOL-UID-21A (10/99)
Employer's Report of Wages Paid to Each Employee
Continuation Sheet
PLEASE TYPE THIS REPORT
1. Account No.
Quarter/Year
15. Employee's Social Security Number
16. Employee's Name (Last, First)
17. Total Gross Wages Paid
18. Excess Wages This Quarter
19. Total Gross Wages This Page
20. Total Excess This Page

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