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Form 21C                                                                                                                                                                       Page 1
                                                                               CORRECTION REPORT

                            South Dakota Department of Labor and Regulation,  Reemployment Assistance Division
                              PO Box 4730 • Aberdeen, SD  57402-4730 • Phone 605.626.2312 • Fax  605.626.3347 • dlr.sd.gov/ra

Account Number                                                           RA 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
                                                                                                                                                         Reemployment 
Net Change in Taxable Wages                                                                                                                              Assistance 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

                                                                                                                                                           REV 07/2019

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                                       CORRECTION REPORT

   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 $_______
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                                                                                                                         Page 3

                                       CORRECTION REPORT

   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                                      / 
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                                                                                                            Page 4 

                                       CORRECTION REPORT

   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                                      / 
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                                                                                                            PAGE 5

                                       CORRECTION REPORT

   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                                      / 
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                                                                                                                         Page 6

                                       CORRECTION REPORT

   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 $_______
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                                                                                                                         Page 7

                                       CORRECTION REPORT

   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                                      / 
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