SDEformE0774v4-Form55

SD EForm - 0774 V4 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 55

APPLICATION FOR EXEMPTION OR TRANSFER OR LIABILITY

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 Successor:

Employer Account Number:

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

1. Owner/Corporation/LLC:

Owner name is required

Business Name or DBA:

Required, please provide the business name or Doing Business As name.

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.

2. I hereby make application for exemption from filing all reports required under the reemployment assistance law of South Dakota. I agree to advise SD Reemployment Assistance Division if I have employment again at any time in the future.

2a. If employment ceased or business was discontinued with no successor, give last date wages were paid:

Date must be filled out before printing.

2b. if business was sold, leased or otherwise transferred, please complete the following:

Effective date of disposition:

Date must be filled out before printing.

Date you last paid wages in South Dakota:

Date must be filled out before printing.

Are you retaining any part of the business?

Yes

Please select an option before printing.

Disposed of the business by:

Sale

Merger

Receivership

LLP

LLC

Incorporation

Dissolution

Partnership

Other

If you answered "Other" please explain.

Please select an option before printing.

3. Name of Successor:

Please fill out business name before printing.

Phone:

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

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.

Type of Organization:

Please select an option before printing.

Indvidual

Corporation

LLP

LLC

Partnership

Other

If you answered "Other" please explain.

4. It is agreed between the Former Owner and the New Owner that: Please select an option before printing.
All

None

Portion
of the Employer's Experience Rating Account Shall be transferred with assets and liabilities following the account, as provided in Section 61-5-42 SDCL.

5. This report must be signed by the owner, partner or authorized official.

Signature:

Date:

Type Your Name:

You must type your name before printing.

Title:

Title is required.

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

Approved Date:

By:

Effective Date:

Termination Date: