Form 21c - Statement To Correct Information Previously Submitted
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2Form 21C (rev. 4/10)
Statement to Correct Information Previously Submitted
South Dakota Department of Labor, 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
Annual taxable wage base:
Explanation:
2006 & prior = $7,000
2011 = $11,000
2007 = $8,500
2012 = $12,000
2008 = $9,000
2013 = $13,000
2009 = $9,500
2014 = $14,000
2010 = $10,000
2015 & later = $15,000
Quarter
Quarter
Quarter
Quarter
Make a copy of
office
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
Net Change in Taxable Wages
Insurance Division
of South Dakota.
Additional Contribution Due
9
Reduction in Contribution
8
Adjustments
Interest/Penalty
7
Total Payment/Refund
I certify all information on this report is complete and correct.
Signature
Title
Date
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