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EMPLOYER'S REEMPLOYMENT ASSISTANCE QUARTERLY REPORT
Form 21 (rev. 07/19) South Dakota Department of Labor and Regulation, Reemployment Assistance (RA) Tax Division
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.
Quarter/Year Due Date File online at dlr.sd.gov/ra/businesses
/ 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"
1st month 2nd month 3rd month 11. Interest: Line 9 x 1.5% per month from due date %
12. Penalty for late filings: $25.00 per month
2. Does this account operate in more than one
location in South Dakota? Yes No 13. Penalty for late payments: $25.00 per month
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
this quarter, each owner must submit a report. Make remittance payable to "SD Unemployment Insurance"
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your check to make an EFT, funds may be withdrawn from your account as soon as the same day we receive your payment.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

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                                                                                                                                                       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

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                                                                                                                                                 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

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                                                                                                                                                 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

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                         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):

LINE 15                                 CHANGE IN BUSINESS OPERATION OR OWNERSHIP
                            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 ________________

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INSTRUCTIONS FOR COMPLETING EMPLOYER'S REEMPLOYMENT ASSISTANCE QUARTERLY REPORT
Report and remittance are considered received on date shown on postmark of envelope in which they are received.
Hint: Using the tab key will guide you through the form in the correct order.
WAGE REPORT. Each page must show a total with a grand total LINE 15. CHANGES IN BUSINESS OPERATION OR
on the last page. OWNERSHIP. GO TO LINE 10 & LINE 15 WORKSHEET.
INTERNET REPORTING. Employers have the option to submit DISCONTINUANCE OF BUSINESS. Enter the date that wages were
quarterly wage information online, by entering wage information or last paid.
by uploading a file. The Internet site can be accessed at the SD
Department of Labor and Regulation website BUSINESS SOLD, LEASED OR OTHERWISE TRANSFERRED.
Complete Line 15 (Form 55) portion in full, showing the name of the
www.sdwagereport.com.
successor or successors and the effective date of the disposition.
ACCOUNT NUMBER, BUSINESS NAME, ADDRESS. Enter your The Reemployment Assistance Law permits the transfer of the
RA account number, and your business name and address. employer's payroll experience and experience rating account.
QUARTER/YEAR. Enter the quarter and the two-digit year the Therefore, be specific as to whether you authorize the transfer of
report is for. your experience rating account to the successor in the business.
DUE DATE. Report due by last day of month, following end of SIGNATURE. This report must be signed by (1) the individual, if the
quarter. Q1 due by 4/30, Q2 due by 7/31, Q3 due by 10/31, and Q4 employer is an individual; (2) the President, Treasurer or other
due by 1/31. principal officer, if the employer is a corporation; or (3) a
responsible duly-authorized member or agent having knowledge of
RA CONTRIBUTION RATE. Enter your current Reemployment company affairs.
Assistance tax rate on Line 6.
LINE 16. EMPLOYEE'S SOCIAL SECURITY NUMBER. The
ADMINISTRATIVE FEE. Enter your current Administrative Fee on employee's Social Security number is required. Those without
Line 7. Social Security numbers must apply for one. Enter without hyphens.
INVESTMENT FEE. Enter Investment Fee rate on Line 8. LINE 17. EMPLOYEE'S NAME. Enter employee's full name in this
LINE 1. NUMBER OF WORKERS. The monthly employment data order: Last Name, First Name (up to 11 characters).
reported on the Quarterly Contribution Report should be a count of LINE 18. TOTAL GROSS WAGES PAID THIS QUARTER. Enter
all full-time and part-time workers who worked during or received gross wages paid this quarter subject to the Reemployment
pay (subject to RA wages) for the payroll period that includes the Assistance Law. Wages paid include: money wages paid for
12th of the month. employment, commissions paid, any special cash payment (such
LINE 2. LOCATIONS. Mark "Yes" if your business has more than as cash gifts, cash prizes or cash bonuses), reasonable cash value
one location. of remuneration for services paid in a medium other than cash
LINE 3. TOTAL GROSS WAGES PAID THIS QUARTER. This line (such as lodging, meals, free or paid rent, etc.), and special
is calculated from the individual gross wages you enter on Line 18. payments made in any medium (such as gifts and prizes). Tips are
See Line 18 instructions for more information. also reportable in most instances. Employee contributions to tax-
deferred wages under an income-tax-deferred retirement plan or
LINE 4. WAGES PAID THIS QUARTER IN EXCESS OF ANNUAL cafeteria (Sec. 125) plan are taxable. Employer contributions to
WAGES BASE. This line is calculated from the individual excess retirement or pension plans established under USC 26: 401(k),
wages you enter on Line 19. See Line 19 instructions for more 403(b), 408(k), 457 or 408(p) are not reportable wages.
information.
LINE 19. EXCESS WAGES PAID THIS QUARTER. Enter the
LINE 5. TAXABLE WAGES. Excel subtracts Line 4 from Line 3. portion of Line 18 paid to each individual during this quarter that
LINE 6. UI CONTRIBUTION. Excel multiplies wages from Line 5 by exceeds the annual taxable wage base for the calendar year. This
rate listed. This tax is reported on IRS Form 940. will include only the wages paid this quarter in excess of the annual
LINE 7. ADMINISTRATIVE FEE. Excel multiplies wages from Line taxable wage base for the individual. The taxable wage base for
5 by the rate listed. This tax is not included on IRS Form 940. 2015 and after is $15,000.
LINE 8. INVESTMENT FEE. Excel multiplies wages from Line 5 by LINE 20. GROSS WAGES THIS PAGE. Excel sums all wages in
rate listed. This tax is not included on IRS Form 940. Line 18 for this page.
LINE 9. TOTAL TAX DUE. Excel calculates the total amount of tax LINE 21. TOTAL EXCESS WAGES THIS PAGE. Excel sums all
due by adding Lines 6, 7 and 8. excess wages in Line 19 for this page. This total cannot exceed the
amount on Line 20.
LINE 10. ADJUSTMENTS. Enter the amount of any debit or credit
notices received from the Department or adjustments from prior LINE 22. TOTAL GROSS WAGES ALL PAGES. Excel sums Line
quarters you may have found. Excel includes this amount in total on 20 from all pages and also enters it on Line 3.
Line 14. Enter an explanation on the Line 10 & 15 worksheet. LINE 23. TOTAL EXCESS WAGES ALL PAGES. Excel sums
LINE 11. INTEREST. Enter the interest rate if the report is late. Line 21 from all pages and also enters it on Line 4. This total cannot
Interest is 1.5% per month (or fraction of a month) from the due exceed the amount on Line 22.
date of a report. Excel calculates the interest due by multiplying the SIGNATURE. This report must be signed by the employer or on the
payment due (Line 9) by interest rate listed. employer's behalf by someone having personal knowledge of the
LINE 12. PENALTY FOR LATE FILING. If the report is late, enter facts herein stated and who has been authorized to sign such a
the penalty amount. The penalty for filing a report late is $25 per report.
month (or fraction of a month) from the due date. The maximum PREPARED BY. Enter report preparer’s name, telephone number,
penalty is $150 per quarterly report. and email address.
LINE 13. PENALTY FOR LATE PAYMENT. If the payment is late,
enter the penalty amount. The penalty for being late making full
payment is $25 per month (or fraction of a month) from the due
date. The maximum penalty is $150 per quarterly report.
LINE 14. TOTAL REMITTANCE. Excel sums Lines 9 through 13.

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