Marcia Hultman

Cabinet Secretary

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Unemployment Insurance (UI)


RA Benefits Forms

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

Direct Deposit Form
Medical Statement of Ability to Work
Weekly Request for Payment
Claimant Change of Name and Address Form
Name and address may also be updated online at or by calling 605.626.2452.

Employer Contacts Form (Job Search Tracking Sheet)
This form also in the back of the Facts About Reemployment Assistance (PAM247) booklet


RA Tax Forms

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

Register Your Business


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


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


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

Credit Card Authorization Form (Adobe PDF - Print and mail or fax)
Report Fraud (Complete online and submit or print and mail or fax)

Appeals Forms

Complete online, then print and mail or fax.

Appeal of and Request for Hearing on Determination or Request for Waiver of Overpayment (Form UID-A1)

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