Form 21C (rev. 01/18)
Statement to Correct Information Previously Submitted
South Dakota Department of Labor and Regulation, Unemployment Insurance Division
PO Box 4730 • Aberdeen, SD 57402-4730 • Phone 605.626.2312 • Fax 605.626.3347 • www.sdjobs.org
Account Number
UI Rate
%
Employer
Year
Admin Rate
%
Address
IF Rate
%
A separate report is required for each year.
Total Rate
%
Amount Reported on Original Report
Correct Amount
Qtr/Yr to
Total Wages
Wages Paid in
Total Wages
Wages Paid in
Employee Name
Paid This Quarter
Social Security #
be Corrected
Excess of $________
Paid This Quarter
Excess of $________
/
1
/
2
/
3
/
4
/
5
/
6
/
7
/
8
Explanation:
Annual taxable wage base:
2015 & later = $15,000
Quarter
Quarter
Quarter
Quarter
office
Make a copy of
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
7
(1.5% per month from due date)
Penalty
7
Total Payment/Refund
I certify all information on this report is complete and correct.
Signature
Title
Phone
Date
Form 21C (rev. 01/18)
Statement to Correct Information Previously Submitted
South Dakota Department of Labor and Regulation, Unemployment Insurance Division
PO Box 4730 • Aberdeen, SD 57402-4730 • Phone 605.626.2312 • Fax 605.626.3347 • www.sdjobs.org
Account Number
UI Rate
%
Employer
Year
Admin Rate
%
Address
IF Rate
%
A separate report is required for each year.
Total Rate
%
Amount Reported on Original Report
Correct Amount
Qtr/Yr to
Total Wages
Wages Paid in
Total Wages
Wages Paid in
Employee Name
Paid This Quarter
Social Security #
be Corrected
Excess of $________
Paid This Quarter
Excess of $________
/
1
/
2
/
3
/
4
/
5
/
6
/
7
/
8
Explanation:
Annual taxable wage base:
2015 & later = $15,000
Quarter
Quarter
Quarter
Quarter
office
Make a copy of
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
7
(1.5% per month from due date)
Penalty
7
Total Payment/Refund
I certify all information on this report is complete and correct.
Signature
Title
Phone
Date
Form 21Cc (rev. 01/18)
Statement to Correct Information Previously Submitted
South Dakota Department of Labor and Regulation, Unemployment Insurance Division
PO Box 4730 • Aberdeen, SD 57402-4730 • Phone 605.626.2312 • Fax 605.626.3347 • www.sdjobs.org
Account Number
Employer
Year
Amount Reported on Original Return
Correct Amount
Qtr/Yr to
Total Wages
Wages Paid in
Total Wages
Wages Paid in
Social Security #
Employee Name
be Corrected
Paid This Quarter
Excess of $_________
Paid This Quarter
Excess of $_________
/
1
/
2
/
3
/
4
/
5
/
6
/
7
/
8
/
9
/
10
/
11
/
12
/
13
/
14
/
15
/
16
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17
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