The credit card authorization form from the South Dakota Department of Labor and Regulation (DLR) is the form a card holder signs to authorize the Reemployment Assistance Division to charge a credit card. The DLR lists it among its Overpayments Forms, to be printed and then mailed or faxed. On FillingPDF you can fill out the form online and download or print the completed PDF; the Division publishes the original PDF at dlr.sd.gov/ra.
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What is Credit Card Authorization Form – South Dakota?
The Credit Card Authorization Form (printed on the form as CREDIT CARD AUTHORIZATION-BPC) is the South Dakota Department of Labor and Regulation (DLR) form on which a card holder authorizes the Reemployment Assistance Division to charge a credit card for a payment.
The form collects three kinds of information. First, the payment option: a one-time payment processed on a date you give, or a recurring payment with the dates and a start date you choose. Second, the card: Visa, Mastercard, Discover or American Express, the card number, the expiration date, the CVC and the payment amount. Third, the people involved: the card holder's name as it appears on the card, an SSN number, the claimant's full name, an address and a phone number.
By signing, the card holder authorizes the DLR Reemployment Assistance Division to charge the card. The form states that if a payment cannot be processed, this method of payment will be canceled and the card holder will be notified in writing.
The Division lists the form under Overpayments Forms on its Reemployment Assistance forms page, marked "Print and mail or fax". It is separate from the Appeal Request and the Request for Financial Waiver of Overpayment, which the same page lists under Appeals and Waiver Forms. The block marked For Accounting Use Only is for the Division, not for you.
Who needs to file Credit Card Authorization Form – South Dakota?
A person who wants to pay the DLR Reemployment Assistance Division by credit card uses this form. The Division lists it under Overpayments Forms on its Reemployment Assistance forms page.
The form separates two people, although they may be the same:
- The card holder, who enters the name exactly as it appears on the card, supplies the card details and signs and dates the authorization.
- The claimant, whose full name and SSN number the form also asks for.
Only the card holder's signature authorizes the charge, so the person whose name is on the card is the one who signs.
The form does not take payments or card information by email. If you want to appeal an overpayment determination or request a financial waiver, the Division lists separate forms for that, the Appeal Request and the Request for Financial Waiver of Overpayment; this form does neither.
When to file Credit Card Authorization Form – South Dakota
The form has no due date printed on it. You submit it when you choose to pay the Reemployment Assistance Division by credit card, and the dates that matter are the ones you enter yourself.
For a one-time payment, you enter the date on which the payment is to be processed, in MM/DD/YYYY format. For a recurring payment, you choose one or two payment dates and a start date, also in MM/DD/YYYY format. The form prints "(6-24)" beside the recurring dates; check the printed form for how that range applies.
Because the form must be mailed or faxed, allow for delivery time before the date you want the payment processed. If a payment cannot be processed, the form states that this method of payment will be canceled and the card holder notified in writing.
How to fill out Credit Card Authorization Form – South Dakota
Choose a payment option
Under Payment Options, choose One-Time or Recurring. Choose one option, not both.
Enter the payment dates
For a one-time payment, enter the date to process the payment in MM/DD/YYYY format. For a recurring payment, choose one or two payment dates (the form prints "6-24") and enter the start date in MM/DD/YYYY format.
Select the card type
Under Credit Card Information, mark Visa, Mastercard, Discover or American Express.
Enter card number, expiration and CVC
Write the card number, the expiration date in MM/YYYY format and the CVC.
Enter the payment amount
Write the amount to be charged in the Payment Amount field, which is preceded by a dollar sign.
Enter the card holder's name
Under Card Holder's Name, write the First Name, Middle Initial and Last Name exactly as they appear on the card listed above.
Enter SSN and claimant's name
Fill in the SSN Number and the Claimant's Full Name as the form asks.
Enter address and phone number
Write the Address, City, State, Zip and Phone Number in the fields provided.
Add special instructions if needed
Use the Special Instructions line for any note to the Division. Leave the For Accounting Use Only box blank; the Division completes it.
Sign and date the authorization
The card holder signs on the Signature of Card Holder line and enters the date. The signature authorizes the DLR Reemployment Assistance Division to charge the card.
Review, download and send
Check the dates, card details and name against the card, then download or print the completed PDF from FillingPDF. Mail or fax it as described under How to submit.
How to submit Credit Card Authorization Form – South Dakota
You can send the signed form to the Division by mail or by fax. The form states that it must be mailed or faxed, and that credit card information or payments cannot be accepted by email.
- By mail: South Dakota Department of Labor and Regulation, Reemployment Assistance Division, 420 S. Roosevelt St., PO Box 4730, Aberdeen, SD 57402-4730. This is the address printed on the form.
- By fax: 605.626.2216.
The Division's telephone number, as printed on the form, is 605.626.7649. The Division's forms page describes this form as one to print and then mail or fax. It does not give a fee or a processing time for this form.
Do not fill in the For Accounting Use Only box (Processed By, Date Processed). FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Emailing the form. It states that credit card information or payments cannot be accepted via email, and that it must be mailed or faxed.
- Sending the form without the card holder's signature and date. The authorization to charge the card takes effect by signing.
- Entering a name that differs from the card. The card holder's name must be as it appears on the card listed on the form.
- Writing dates in the wrong format: MM/DD/YYYY for the payment and start dates, MM/YYYY for the card expiration date.
- Choosing more than one payment option, or listing more than the one or two payment dates the recurring option allows.
- Leaving out the claimant's full name or the SSN number, which the form asks for in addition to the card holder's name.
- Writing in the For Accounting Use Only box, which the Division completes (Processed By, Date Processed).
- Assuming a failed payment will be retried. The form states that if a payment cannot be processed, this method of payment will be canceled and you will be notified in writing.
Frequently asked questions
What is the South Dakota credit card authorization form for?
It authorizes the South Dakota DLR Reemployment Assistance Division to charge a credit card. The card holder gives card details, picks a one-time or recurring payment and signs. The Division lists the form under Overpayments Forms on its forms page.
Can I email my credit card authorization form to the DLR?
No. The form states it must be mailed or faxed, and that credit card information or payments cannot be accepted via email. Fax it to 605.626.2216 or mail it to the Reemployment Assistance Division, PO Box 4730, Aberdeen, SD 57402-4730.
Can I set up recurring payments with this form?
Yes. Under Payment Options you can choose Recurring instead of One-Time, pick one or two payment dates (the form prints "6-24") and enter a start date in MM/DD/YYYY format. A one-time payment uses a single processing date.
Who signs the credit card authorization form?
The card holder signs and dates it on the Signature of Card Holder line. The form asks for the card holder's name as it appears on the card and, separately, the claimant's full name, so the two can be different people.
What happens if my payment cannot be processed?
The form states that this method of payment will be canceled and you will be notified in writing. It does not describe a retry, so contact the Division at 605.626.7649 about how to pay instead.
Can I fill out the credit card authorization form online?
You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is independent of the DLR and does not send the form or process the payment; you mail or fax it to the Division yourself.
Is this the form to appeal an overpayment or ask for a waiver?
No. The DLR lists a separate Appeal Request and a Request for Financial Waiver of Overpayment under Appeals and Waiver Forms. This form only authorizes a credit card charge.
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