Form 1np - Registration Report To Determine Liability For 501(C)(3) Nonprofit Organizations
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SD EForm -
0763 V2
HELP
REGISTRATION REPORT TO DETERMINE LIABILITY
(rev. 4/11)
Form 1NP
FOR 501(c)(3) NONPROFIT ORGANIZATIONS
South Dakota Department of Labor and Regulation
South Dakota Department of Labor
Unemployment Insurance Division
PO Box 4730, Aberdeen, SD 57402 • Phone 605.626.2312 • Fax 605.626.3347 •
This report must be completed whether or not you are liable for contributions under the South Dakota Unemployment Insurance Law, and
returned to the Division within 10 days.
Do Not Write In This Space – SD DLR Use Only
-
1. Enter your Federal Identification Number:
NAICS Code
Account Number
Account Number:
C-number
Employer
Liability Begins
2. Phone Number
Cell
Liability Code
Applicable
UI
Rates
Fax Number
IF
& Date
Territory
Reviewer
Contact Person(s)
Date
Account Code
N
P
P-Number
Email Address
Type of Election
Bond
3. Owner or Corporate Name
Contribution
Reimbursement
Percentage
Yes
No
4. Business Name
5. Mail Address
(Address)
(City)
(State)
(Zip Code)
6. Business Headquarters Address
(Street Address)
(City)
(State)
(Zip Code)
Type Of Organization: (Check One)
1. Corporation
2. Association
3. Other Explain
If a Corporation, please complete the following questions:
State of Incorporation
Date of Incorporation
Date Qualified in S.D.
Name of Statutory Agent
Address
7. Identification Of Principal Administrative Officers:
Social Security Number
Name
Title
Residence Address
8. Work Locations:
Nature of Business
(List additional locations In Comment Section)
Street Address
City
Primary Activity
Principal Product/Service
(A)
(B)
9. Date of First Employment in South Dakota:
10. Weekly Record Of Employment:
Enter the number of individuals performing services for you on the day in which you employed the largest number
within each calendar week ending at midnight Saturday.
January
February
March
April
May
June
Year
July
August
September
October
November
December
January
February
March
April
May
June
Year
July
August
September
October
November
December
11. We elect the following method of payment: (check one) (See next page for information on available options.)
1. To pay contributions as an employer as provided in chapter 61-5 SDCL.
2. Elect reimbursement of benefits in lieu of contributions as provided in chapter 61-5a-6 SDCL.
3. Periodic billing for payment in lieu of contributions based on payroll as provided in chapter 61-5a-28 SDCL.
12. Signature
This report must be signed by an elected officer of the organization, a principal administrative officer, or a responsible and duly authorized
:
member having knowledge of the organization.
I hereby certify that the information contained in this report is true and correct to the best of
my knowledge, information and belief.
Signature_____________________________________________Title_________________________
Print Name____________________________________________Date_________________________
Registration
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