SD EForm - 0762V5 Form 1

SD EForm - 0762 V5 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 - 1

EMPLOYER REGISTRATION APPLICATION

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

If you are a PEO, you must register this account under your client’s FEIN and business information.
If you are a TPA, go to www.sdjobs.org to complete and submit a POA.

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

Reviewer's Initials/Date:

County Code

Account Number

C-Number

Liable Date

Qualify Code

Territory

Qualify Date

Account Code

N P

Wage Successor

Year

Rates

FEIN:

Type of Business: (Check One)

Please select an option before printing.

Standard

Domestic

Agricultural

501C3

Government

Tribal

Legal Name:

Legal Name is required

Business Phone:

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

Doing Business As:

Doing Business Name is required

Business Fax:

Addresses: (PO Box/Street/City/State/Zip)

Primary Mailing:

Primary Mailing address is required.

Business Headquarters: (if different than mailing address)

Benefit Claims: (if different than mailing address)

Work location(s) in South Dakota: (e.g. office street address, location of job site, if you do not maintain an office in South Dakota, enter employee’s home address. )

Business Email:

Invalid Email, please format your email as: johndoe@example.com

Contact Information:

Name:

Contact Name is required

Phone:

Mobile:

Email:

Invalid Email, please format your email as: johndoe@example.com

Type of Ownership:

Please select an option before printing.

Individual

Partnership

Corporation

Association

Government

School District

Tribal

LLC

If LLC, type of income tax return filed:

1040

1065

1120

1120S

Unknown

Please select an option before printing.

Ownership: (Owner/Partners/Corporate Officers/Members)

Social Security Number	Name	Title	Address

Employment Information:

Are you reinstating an inactive Account?

Please select an option before printing.

Yes

If so, enter account number:

Did you acquire in full or part, an already established business?

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Yes

If yes, please complete Change in Ownership section.

Are you liable under the Federal Unemployment Tax Act?

Please select an option before printing.

Yes

If Yes, what year?

If you answered yes, please indicate what year, i.e. 2019.

Are you liable under the unemployment laws of another state?

Please select an option before printing.

Yes

Enter the date you first had employment in South Dakota:

Enter the date you first paid wages to employees in South Dakota:

Enter the Saturday ending date of the twentieth week in which you had:

(Standard, 1 or more employees, Agricultural, 10 or more employees, 501 C 3, 4 or more employees)

Enter gross quarterly payroll. Include only wages for work performed in South Dakota, through the current date. Do not include wages you expect to pay in the future. Any remuneration to corporate officers, including distributions and dividend in lieu of wages, is reportable.

Year	1st Qtr	2nd Qtr	3rd Qtr	4th Qtr
Current Year
Preceding Year
Preceding Year

Change in Ownership Information:

Complete if you acquired in full or part, an already established business.

Name of Business Acquired:

Owner Name:

Date of acquisition:

FEIN

SD RA Account Number:

It is agreed between the former owner and the new owner that: All None Portion* of the employer’s experience rating account shall be acquired with the assets and liabilities following the account as provided in SDCL 61-5-42. If the ownership, management, or control of the successor is substantially the same as the predecessor, a transfer of the experience rating account will be mandatory.

*If you elect to transfer a Portion of the experience rating account, you must provide a list of the taxable payroll by quarter and year for the current and four preceding years. The list must include the name, Social Security Number, and taxable wages paid by quarter and year for the portion of the business being transferred. There must be two segreable units of business with separate records maintained to qualify for a partial transfer.