Marcia Hultman

Cabinet Secretary

Font Size: A A A

Reemployment Assistance (RA)

Forms

RA Benefits Forms

The RA Benefits forms available below are in Adobe PDF format.

Employee/Claimant Benefit Forms

Claimant Change of Name and Address Form
Name and address may also be updated online at RAClaims.sd.gov or by calling 605.626.2452.

Direct Deposit Form
Employer Contacts Form (Job Search Tracking Sheet)
This form also in the back of the Facts About Reemployment Assistance (PAM247) booklet
Medical Statement of Ability to Work
Overpayments and Appeals forms
Weekly Request for Payment
The preferred and faster methods for submitting weekly requests are online at RAClaims.sd.gov or through the automated phone system at 605.626.3212. however you may contact the Customer Service Center at 605.626.2452 if you need a printed form.

You may use this form for backdate and late payment requests as well. Complete one form for each week you are requesting back pay. The RA Division will review to determine eligibility. Back date and late payment requests cannot be done online or through the automated phone system.

Employer Forms

Employee Recall Date Form
Employers who have furloughed employees and will be recalling them, please provide recall dates if you have not already done so. You may also call 605.626.2452 with this information.
Employer Reporting Refusal of Work When Recalled
Report employees who have been placed on temporary layoff but refuse to return to work or quit without good cause. See Refusal to Work page for more information.
(Open this form in an Adobe reader program to complete. Changes made in your internet browser will not save.)
Employer Reporting No Shows or Refusal of Work/Interviews Report individuals who refuse to interview or to accept a suitable job offer, do not show up for work, etc. See Refusal to Work page for more information.
(Open this form in an Adobe reader program to complete. Changes made in your internet browser will not save.)

 

RA Tax Forms

You can complete most RA Tax forms online, then print and mail or fax.

Register Your Business

TWO WAYS TO REGISTER

Register your business online and receive your account number and assigned rates immediately.
Log in to Register Your Business


OR

Complete, print and mail
Employer's Registration Application (Form 1)

Employer's Quarterly Report/Annual Contribution and Wage Report Forms

Online Employer’s Reemployment Assistance Quarterly Report
Log in to File a Quarterly Report

OR

Print, complete and mail (Adobe PDF):
Employer's Reemployment Assistance Quarterly Report (Form 21)

Correct Information Previously Submitted (Form 21C)

Excel format
| PDF format (print, then complete)
Employer’s Annual Contribution, Investment Fee and Wage Report (Form 21D and Form 21E):

Excel format | PDF Format (print, then complete)

Additional RA Tax Forms

Application For Designation as Seasonal Employer (Form 26)
Application for Exemption or Transfer of Liability (Form 55)
Domestic Employer Application to Withdraw from Annual Wage and Contribution Reporting (Form WDE)
Domestic Employer Election to Report Quarterly Wages and Pay Contributions Annually (Form DE)
Employer's Report on Acquiring a Business (Form 49)
Payment Agreement (Form 10)
Power of Attorney/Authorization of Agent (Form POA)
Registration for State Information Data Exchange System (SIDES) E-Response (SIDES E-Response Registration Form)
Worker Relationship Questionnaire (Form 23)

 

Overpayments Forms

See Appeals and Waiver section to request an appeal of an overpayment determination or if you've been determined not at fault and wish to request a financial waiver.
Credit Card Authorization Form (Adobe PDF — Print and mail or fax)
Report Fraud (Complete online and submit or print and mail or fax)


Appeals and Waiver Forms

Open forms in an Adobe reader program to complete. Changes made in your internet browser may not save. Then print, sign, and mail, fax or drop off at your Job Service office. We cannot accept appeals or waiver requests over the phone or by email.

Appeal Request (Adobe PDF — Print and mail or fax)
Complete this form if you disagree with a determination made by the Division and are requesting a hearing or have an overpayment determination that puts you at fault, and you would like to request a review of that determination. You may also request a financial waiver.
Request for Financial Waiver of Overpayment (Adobe PDF — Print and mail or fax)
Complete this form if you have an overpayment and it has been determined you are not at fault, and you would like to request a financial waiver.
View Family Income Table for Overpayment Waiver Provision

back to top