DLR – RA 300
PAGE 1
REV 05/02/2020
SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION
REEMPLOYMENT ASSISTANCE
P.O. Box 4730, Aberdeen, SD 57402 Fax: 605.626.3172 raclaims.sd.gov
BACKDATE AND LATE PAYMENT REQUEST
CLAIMANT NAME: ____________________________________________ SSN: ________________________
Current Effective Date of Claim: ____________
Backdating Requesting Start Date of (must be a Sunday):___________________
Week Ending Date:
(Saturday)
____________
MM/DD/YYYY
____________
MM/DD/YYYY
____________
MM/DD/YYYY
During the week that ended in the date in the row
above, did you work for an employer or in self-
employment? (If yes, add information for each employer on Pg
2)
YES NO YES NO YES NO
Total number of hours you worked during the week (with all
employers or self-employment):
_______ hrs _______ hrs _______ hrs
Gross total amount of wages you earned in dollars and
cents (before deductions): (Combine all wages earned this
week before any deductions and/or self-employment
earnings after expenses)
$ __________ $ __________ $ __________
If worked but had no earnings, was it because you
attempted commission sales, were self-employed, or
have other unpaid hours?
YES NO YES NO YES NO
Are you still working for this employer?
YES NO YES NO YES NO
SECTION B: Did you or will you receive any of the following for this week?
HOLIDAY PAY?
YES NO
If yes, gross amount
$
YES NO
If yes, gross amount
$
YES NO
If yes, gross amount
$
VACATION PAY OR ANNUAL LEAVE? YES NO
If yes, gross amount
$
YES NO
If yes, gross amount
$
YES NO
If yes, gross amount
$
SICK PAY? YES NO
If yes, gross amount
$
YES NO
If yes, gross amount
$
YES NO
If yes, gross amount
$
SEVERANCE PAY/WAGES IN LIEU OF NOTICE? YES NO
If yes, gross amount
$
YES NO
If yes, gross amount
$
YES NO
If yes, gross amount
$
Will you begin receiving pension, disability payments or
workers’ compensation or did the amount previously
reported change?
YES NO
If yes, explain in remarks
YES NO
If yes, explain in remarks
YES NO
If yes, explain in remarks
Are you on call to return to work for your regular employer? YES NO YES NO YES NO
Were you physically and mentally able to work?
YES NO
if no, explain in remarks
YES NO
if no, explain in remarks
YES NO
if no, explain in remarks
Were you available to accept a job if offered?
YES NO
if no, explain in remarks
YES NO
if no, explain in remarks
YES NO
if no, explain in remarks
Did you refuse any offer of work or referral to work?
YES NO
If yes, explain in remarks
YES NO
If yes, explain in remarks
YES NO
If yes, explain in remarks
Did you begin school or did your class schedule change
during the week?
YES NO YES NO YES NO
FAILURE TO ANSWER ANY OF THE ABOVE QUESTIONS WILL DELAY PROCESSING OF THIS CLAIM.
YOU CANNOT REQUEST BACKDATING UNTIL YOU HAVE RECEIVED A MONETARY DETERMINATION.
CERTIFICATION: I certify that my statements are true and correct and I am aware of the penalties for all false statements on my claim.
Claimant’s Signature
____________________________________________________________ Date: _________________
BACKDATE
REQUEST ONLY
SECTION A:
If no, skip to Section B
(Starts with Holiday Pay)
I f no, skip to Section B
( Sta rts with Holiday Pay)
If no, skip to Section B
(St arts with Holiday Pay)
>
Effective date is on your monetary determination The Sunday after the first week.
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