Form 21 "Employer's Reemployment Assistance Quarterly Report" - South Dakota

What Is Form 21?

This is a legal form that was released by the South Dakota Department of Labor & Regulation - a government authority operating within South Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the South Dakota Department of Labor & Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 21 by clicking the link below or browse more documents and templates provided by the South Dakota Department of Labor & Regulation.

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Download Form 21 "Employer's Reemployment Assistance Quarterly Report" - South Dakota

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EMPLOYER'S REEMPLOYMENT ASSISTANCE QUARTERLY REPORT
South Dakota Department of Labor and Regulation, Reemployment Assistance (RA) Tax Division
Form 21
(rev. 07/19)
PO Box 4730 • Aberdeen, SD 57402-4730 • Phone 605.626.2312 • Fax 605.626.3347 • dlr.sd.gov/ra
Account Number
Instructions available in "Instructions" tab.
File online at dlr.sd.gov/ra/businesses
Quarter/Year
Due Date
/
3. Total gross wages paid in this quarter (Item 22)
Business Name and Address
4. Wages paid this quarter in excess of annual per person (Item 23)
5. Taxable wages (Item 3 minus Item 4)
6. RA contribution rate
% x line 5
7. Administrative fee rate
% x line 5
8. Investment fee rate
% x line 5
1. For each month, report the number of covered workers who worked during or
9. Total due (add lines 6, 7 & 8)
received pay for the payroll period which includes the 12th of the month.
10. Adjustment from prior quarters (explain on
"Line 10 & Line 15"
tab)
If none, enter "0"
11. Interest: Line 9 x 1.5% per month from due date
%
1st month
2nd month
3rd month
12. Penalty for late filings: $25.00 per month
2. Does this account operate in more than one
Yes
No
13. Penalty for late payments: $25.00 per month
location in South Dakota?
15. If your business in South Dakota has changed in any way, please
14. Total remittance (sum of lines 9 through 13)
complete the "Line 10 & Line 15" worksheet. If the ownership changed during
Make remittance payable to "SD Unemployment Insurance"
this quarter, each owner must submit a report.
Note: When you make a check payment, you authorize us to use information from your check to make a one-time electronic funds transfer (EFT) from your account. When we use information from
your check to make an EFT, funds may be withdrawn from your account as soon as the same day we receive your payment. You will not receive your check back from your financial institution.
16.
Employee's Social Security Number
17. Employee's Name (Last, First)
18. Total Gross Wages Paid This Quarter
19. Excess Wages Paid This Quarter
Signature
I certify all information on this report is complete and correct.
20. Total Gross Wages This Page
21. Total Excess Wages This Page
Title
Date
22. Total Gross Wages All Pages
23. Total Excess Wages All Pages
Prepared by
Telephone
Email Address
EMPLOYER'S REEMPLOYMENT ASSISTANCE QUARTERLY REPORT
South Dakota Department of Labor and Regulation, Reemployment Assistance (RA) Tax Division
Form 21
(rev. 07/19)
PO Box 4730 • Aberdeen, SD 57402-4730 • Phone 605.626.2312 • Fax 605.626.3347 • dlr.sd.gov/ra
Account Number
Instructions available in "Instructions" tab.
File online at dlr.sd.gov/ra/businesses
Quarter/Year
Due Date
/
3. Total gross wages paid in this quarter (Item 22)
Business Name and Address
4. Wages paid this quarter in excess of annual per person (Item 23)
5. Taxable wages (Item 3 minus Item 4)
6. RA contribution rate
% x line 5
7. Administrative fee rate
% x line 5
8. Investment fee rate
% x line 5
1. For each month, report the number of covered workers who worked during or
9. Total due (add lines 6, 7 & 8)
received pay for the payroll period which includes the 12th of the month.
10. Adjustment from prior quarters (explain on
"Line 10 & Line 15"
tab)
If none, enter "0"
11. Interest: Line 9 x 1.5% per month from due date
%
1st month
2nd month
3rd month
12. Penalty for late filings: $25.00 per month
2. Does this account operate in more than one
Yes
No
13. Penalty for late payments: $25.00 per month
location in South Dakota?
15. If your business in South Dakota has changed in any way, please
14. Total remittance (sum of lines 9 through 13)
complete the "Line 10 & Line 15" worksheet. If the ownership changed during
Make remittance payable to "SD Unemployment Insurance"
this quarter, each owner must submit a report.
Note: When you make a check payment, you authorize us to use information from your check to make a one-time electronic funds transfer (EFT) from your account. When we use information from
your check to make an EFT, funds may be withdrawn from your account as soon as the same day we receive your payment. You will not receive your check back from your financial institution.
16.
Employee's Social Security Number
17. Employee's Name (Last, First)
18. Total Gross Wages Paid This Quarter
19. Excess Wages Paid This Quarter
Signature
I certify all information on this report is complete and correct.
20. Total Gross Wages This Page
21. Total Excess Wages This Page
Title
Date
22. Total Gross Wages All Pages
23. Total Excess Wages All Pages
Prepared by
Telephone
Email Address
Page 2
REEMPLOYMENT ASSISTANCE DIVISION
Employer's Report of Wages Paid to Each Employee
Continuation Sheet
/
Account Number
Quarter/Year
16. Employee's Social Security Number
17. Employee's Name (Last, First)
18. Total Gross Wages Paid This Quarter
19. Excess Wages This Quarter
20. Total Gross Wages This Page
21. Total Excess Wages This Page
22. Total Gross Wages All Pages
23. Total Excess Wages All Pages
Page 3
REEMPLOYMENT ASSISTANCE DIVISION
Employer's Report of Wages Paid to Each Employee
Continuation Sheet
/
Account Number
Quarter/Year
16. Employee's Social Security Number
17. Employee's Name (Last, First)
18. Total Gross Wages Paid This Quarter
19. Excess Wages This Quarter
20. Total Gross Wages This Page
21. Total Excess This Page
22. Total Gross Wages All Pages
23. Total Excess All Pages
Page 4
REEMPLOYMENT ASSISTANCE DIVISION
Employer's Report of Wages Paid to Each Employee
Continuation Sheet
/
Account Number
Quarter/Year
16. Employee's Social Security Number
17. Employee's Name (Last, First)
18. Total Gross Wages Paid This Quarter
19. Excess Wages This Quarter
20. Total Gross Wages This Page
21. Total Excess This Page
22. Total Gross Wages All Pages
23. Total Excess All Pages
EMPLOYER’S REEMPLOYMENT ASSISTANCE QUARTERLY REPORT
South Dakota Department of Labor and Regulation
LINE 10
/
/
Quarter Ending
Explanation of Adjustment (attach additional sheet if more space is needed):
CHANGE IN BUSINESS OPERATION OR OWNERSHIP
LINE 15
Application for Exemption or Transfer of Liability (Form 55)
1.
Account Number
Owner and Business Name
Mailing Address
2.
I hereby make application for exemption from filing all reports required under the Reemployment Assistance (RA) law of South Dakota. I agree to
advise the South Dakota RA Division if I have employment again at any time in the future.
If employment ceased or business discontinued without a successor, give last date wages were paid
or
If business was sold, leased or otherwise transferred, please complete the following:
Effective date of disposition
Reason for disposition (sale, merger, etc.)
Date you last paid wages in South Dakota
Are you retaining any part of the business?
Yes
No
3.
Name of Successor
Address of Successor
4.
It is agreed between the Former Owner and the New Owner that:
All
None
Portion
of the employer's
experience rating account shall be transferred with assets and liabilities following the account, as provided in SDCL 61-5-42.
5.
THIS REPORT MUST BE SIGNED BY THE OWNER, PARTNER OR AUTHORIZED OFFICIAL.
Signature
Title
Date
Phone
Email
Address
For SD DLR use only:
Approved date _________________ By _______________
Effective date __________________
Termination date ________________