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
A separate report is required for each year.                  IF Rate   %
                                                    Total Rate          %
                                                                                     Amount Reported on Original Report          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                                                                       /
Explanation:
                                                                                                                                             Annual taxable wage base:
                                                                                                                                             2015 & later = $15,000

                                             office Quarter             Quarter      Quarter           Quarter                               Make a copy of   
                                             coding 3/31/____     6/30/____          9/30/____         12/31/____          Total             this report for your 
Net Change in Total Wages                                                                                                                    records. Send 
                                                                                                                                             original to the 
Net Change in Excess Wages
                                                                                                                                             Unemployment 
Net Change in Taxable Wages                                                                                                                  Insurance Division 
Additional Contribution Due                  9                                                                                               of South Dakota. 
Reduction in Contribution                    8
Adjustments
Interest (1.5% per month from due date)      7
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                                       /
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