RAClaims.sd.gov REV 05/2020
SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION
Reemployment Assistance
COVID-19 Bulk Claim Services
APPLICATION FOR BENEFITS
PLEASE PRINT CLEARLY
Name Social Security Number _____________________
FIRST M LAST
Address
Street City State Zip
Date of Birth
MM/DD/YYYY
White Black Hispanic American Indian Asian Other_____________
Tel: _____________________ E-Mail
Sex: Race (circle one):
I declare, under penalty of perjury, that I (check): am a citizen or national of the United States
have valid employment authorization Alien Reg #: __________________
Highest grade completed _________________ Are you currently attending school or training? YES NO
Are you able and available to work full time? YES
NO:If no, why? ________________________________________________
Are you receiving a pension? YES NO If yes, from whom?_____________________________________________________
Are you receiving severance pay? YES NO If yes, gross
*
amount? _____________
Are you receiving vacation pay? YES NO If yes, gross
*
amount? _____________
Are you receiving sick leave? YES NO If yes, gross
*
amount? _____________
Are you receiving paid holidays? YES NO *gross – amount before taxes
Do you want federal taxes withheld from your benefits? YES NO
Have you filed for unemployment benefits in the last 12 months? YES NO
Current Employer _______________________________________________ Occupation ______________________________
First day of work ______________Last day of work _____________ Reason for Separation _____________________________
I was given a return to work date of ______________ prior to my last day of work.
Previous Employer _______________________________________________ Occupation _____________________________
Address
Street City State Zip
First day of work ______________ Last day of work ___________ Reason for Separation ______________________________
Previous Employer _______________________________________________ Occupation _____________________________
Address
Street City State Zip
First day of work _____________ Last day of work ___________ Reason for Separation _______________________________
I hereby apply for Reemployment Assistance (unemployment) Benefits and request the South Dakota Reemployment
Assistance (RA) Division to determine the amount of benefits I will be eligible to receive if I meet all of the eligibility
requirements of the law. I understand that the law provides for fines, imprisonment, or both in addition to
disqualification and repayment of benefits if I knowingly fail to disclose information or give false information in order to
obtain or increase benefits. I understand that I will receive a monetary determination of benefits, which represents the
base period that determines my weekly benefit amount. I also understand:
• If I fail to return to work on my designated return to work date or refuse to apply for or accept suitable work as directed,
I may be denied benefits after that date.
• If I work during the week I am claiming benefits, I must report all gross earnings regardless if I have been paid yet.
I certify that the information I have given in connection with this application for benefits and fact-finding report is
complete and correct.
Signature _______________________________________________ Date ___________
Use an email address you have access to outside the office
click to sign
signature
click to edit
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