Form 21 - Employer'S Quarterly Contribution, Investment Fee, And Wage Report Page 3

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EMPLOYER’S QUARTERLY CONTRIBUTION, INVESTMENT FEE, AND WAGE REPORT
South Dakota Department of Labor, Unemployment Insurance Division
ITEM 14
IMPORTANT: IF YOUR BUSINESS IN SOUTH DAKOTA HAS CLOSED, NO LONGER HAS EMPLOYEES OR HAD A
CHANGE IN OWNERSHIP, PLEASE COMPLETE ITEMS A OR B BELOW.
A. If business was discontinued without a successor, give date of last employment ______________________________
I hereby make application for exemption from filing all reports required under the Unemployment Insurance Law. I
agree to advise the Unemployment Insurance Division at any date in the future that I again enter business and employ
persons.
B. If the business was sold, leased or otherwise transferred, complete the following:
_____________________________________
Name and address of successor
____________________________________________________
____________________________________________________
Effective date of disposition _______________________________________________________________________
Are you retaining any part of the business? Yes ______ No ______
Number of employees retained _______________________
The Unemployment Insurance Division is hereby authorized to transfer All______ None______ Portion______ of the
experience rating account under the number shown on the face of this report to the above referenced successor.
____________________________________________________________________________________________
Signed (By owner or officer)
Title
Date
ITEM 9
Quarter Ending_________________________________________________________________________________
Explanation of Adjustment:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

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