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Form 10

PAYMENT AGREEMENT

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

Employer name is required

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

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.

Whereas employer is indebted to the Reemployment Assistance Division of the South Dakota Department of Labor and Regulation as follows:

Qtr/Year Contributions Due Interest Due* Penalty Due* Negative Interest Total
Total

*Interest will be assessed at the rate of 1.5% on the first day of each month on the unpaid contributions. Additional penalty charges may also be assessed to unpaid contributions at the rate of $25 per month.

The Department of Labor and Regulation may file a lien for the total amount due. Liens will only be released once contributions, interest, penalty, and negative interest are paid in full. Failure to follow the payment agreement will void this agreement and may result in the issuance of a distress warrant and/or a judgement filed in Small Claims Court.

You must acknowledge the statements below by placing your initials next to each statement.

I agree to make full payment for the amount due, including interest and penalty that will accrue, within six months not to exceed 24 months from the date of this agreement.


I agree to stay current in any future obligations with the Department of Labor and Regulation. This payment agreement pertains only to the outstanding debt contained in this agreement. Failure to follow the payment agreement will void this agreement and may result in the issuance of a distress warrant and/or judgement filed in Small Claims Court.

I, Invalid year, please type correct year format. example: 2019. agree and promise to pay the total listed above including interest and penalty that will accrue, with a first payment of $ Invalid year, please type correct year format. example: 2019. on Invalid year, please type correct year format. example: 2019. and continue to submit monthly payments in the amount of $ Invalid year, please type correct year format. example: 2019. on the Invalid year, please type correct year format. example: 2019. of each month until the entire amount has been paid in full.