SD EForm - 0773 V2 Form 49

SD EForm - 0773 V2 Complete and use the button at the end to print for mailing. To print a blank form, use print options provided by your browser

Form - 49

EMPLOYER'S REPORT ON ACQUIRING A BUSINESS

South Dakota Department of Labor and Regulation
Reemployment Assistance
PO Box 4730
Aberdeen, SD 57402-4730
Phone 605.626.2312 • Fax 605.626.3347

Do Not Write in This Box - For DLR Office Use Only

Transfer:

Into:

Effective:

Wage Success

Year:

Successor's FEIN:

FEIN is required.

Employer Account Number:

Invalid Account Number, Please format account number as: 12345.6-7

1. Owner/Corporation/LLC.:

Owner name is requiedt

Phone:

Invalid Phone Number, format number as: 605-555-1234

2. Business Name:

Please fill out business name before printing.

3. Mailing Address:

Address (PO Box/Street) is required

City is required

State is required

Invalid Zip Code: Make sure the zip code is in the standard US or Canadian format.

4. Type of Organization: (Check One)

Please select an option before printing.

Individual

Partnership

Corporation

Association

LLC

LLP

Other

If you answered "Other" please explain.

5. Work Locations: (include new acquisition)

City	Zipcode	Indicate Specific Activity of Business

6. Acquired business by: (Check One)

Please select an option before printing.

Purchase

Merger

Receivership

Other

7. Date Acquired:

Required, please indicate the date the business was acquired.

Predecessor's Account Number:

Invalid Account Number, Please format account number as: 12345.6-7

8. Predecessor's Name:

The Predecessor's name is required

Address of Predecessor:

Address (PO Box/Street) is required

City is required

State is required

Invalid Zip Code: Make sure the zip code is in the standard US or Canadian format.

9. Did you acquire entire business, organization and assets? If no, describe nature of assets and approximate percentage acquired.

Please select an option before printing.

Yes

If you answered "No" please describe nature of assets and approximate percentage acquired.

10. Number of Employees on date of purchase:

Required, please indicate the number of employees on the date of purchase.

Number of Employees as of this date:

Required, please indicate the number of employees as of today.

11. it was agreed between the successor and the predecssor that: All None Portion Please select an option before printing. of the Employer's Experience rating Account shall be acquired with assets and liabilities following the account, as provided in Secion 61-5-42 SDCL.

12. This Report must be signed by an owner, an elected officer of the organization, a principal administrative officer, or a responsible and duly authorized person having knowledge of the organization.

Signature:

Date:

Type Your Name:

You must type your name before printing.

Title:

Title is required.