Form 10, Payment Agreement, is the form the Reemployment Assistance Division (RA Division) of the South Dakota Department of Labor and Regulation (DLR) uses for an employer's written promise to repay money it owes the Division. The employer lists the debt by quarter and year, initials two acknowledgments and commits to a first payment and then monthly payments until the balance is paid in full. On this page you can fill out the payment agreement online on FillingPDF and download or print the completed PDF; the form itself is published by the DLR at the official link below.
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What is Form 10?
Form 10, Payment Agreement, is the South Dakota Department of Labor and Regulation form in which an employer acknowledges a debt to the Reemployment Assistance Division, listed by quarter and year, and promises to repay it with an initial payment followed by monthly payments.
The form opens with the employer's name, account number and address. A table then breaks the debt into columns: Qtr/Year, Contributions Due, Interest Due, Penalty Due, Negative Interest and Total. A note under the table says interest is assessed on the first day of each month on the unpaid contributions and that additional penalty charges may be assessed on them. The rates are printed on the form.
The agreement also states the consequences of the debt. The Department may file a lien for the total amount due, and a lien is released only when contributions, interest, penalty and negative interest are paid in full. Failing to follow the agreement voids it and may lead to a distress warrant and/or a judgment filed in Small Claims Court.
The employer initials two statements and then signs a promise that names the first payment, its date, the monthly amount and the day of each month on which payments are made. The agreement covers only the outstanding debt written into it. The revision printed on the form is Rev. 01/2026.
Who needs to file Form 10?
Employers that owe money to the Reemployment Assistance Division and want to repay it under a written schedule use this form. It is built around an employer account: it asks for the Employer Name and Employer Account Number, and its opening statement says the employer is indebted to the Division.
Points that decide whether the form fits your situation:
- The agreement pertains only to the outstanding debt listed in it. It does not cover obligations that come later.
- By initialing the second statement, you agree to stay current on any future obligations to the Department of Labor and Regulation.
- You agree to pay in full, including the interest and penalty that accrue, within six months and in no case later than 24 months from the date of the agreement.
The person who signs enters a title next to the signature, along with a printed name, date, email and phone number. The form does not say who within a business may sign, so confirm with the Division before signing for an employer other than yourself.
When to file Form 10
The form is completed when an employer has an outstanding debt to the Reemployment Assistance Division and agrees to repay it in monthly payments. No separate due date is printed on it.
The date of the agreement starts the repayment clock: the employer agrees to pay the full amount, including the interest and penalty that accrue, within six months and not more than 24 months from that date. The promise paragraph sets the date of the first payment and the day of each month on which later payments are made, until the whole amount is paid.
Timing matters after signing. Failure to follow the agreement voids it and may result in a distress warrant and/or a judgment filed in Small Claims Court. A lien the Department may have filed is released only once everything owed is paid in full.
How to fill out Form 10
Enter employer name and account number
At the top, write the Employer Name and the Employer Account Number exactly as they appear on your Reemployment Assistance account.
Enter the employer address
Complete the Address, City, State and Zip fields for the employer.
List the debt by quarter
In the table, add one row for each Qtr/Year owed. Fill in Contributions Due, Interest Due, Penalty Due, Negative Interest and the Total for the row.
Read the lien and default terms
Review the notices that the Department may file a lien for the total due and that failing to follow the agreement voids it and may lead to a distress warrant and/or a Small Claims Court judgment.
Initial both acknowledgments
Place your initials next to each of the two statements: full payment within six months, not to exceed 24 months, and staying current on future obligations.
Complete the payment promise
Enter the name of the person making the promise, the amount and date of the first payment, and the monthly payment amount with the day of each month it is due.
Sign and identify the signer
Sign, then enter the Title, Print Name and Date next to the signature.
Add email and phone
Enter an Email address and Phone number in the last row of the form.
Review and download the completed PDF
Check the table totals, initials, payment dates and signature, then download or print the completed PDF from FillingPDF and confirm the delivery channel with the Division as described under How to submit.
How to submit Form 10
Form 10 does not print a return method, so the channel is set by the Reemployment Assistance Division. The contact details on the form's header are:
- Mail: Reemployment Assistance Division, South Dakota Department of Labor and Regulation, PO Box 4730, Aberdeen, SD 57402-4730.
- Phone: 605.626.2312.
- Fax: 605.626.3347.
- Website: dlr.sd.gov.
The Division's forms page says that most RA Tax forms can be completed online, then printed and mailed or faxed. Because Form 10 itself names no channel, call 605.626.2312 to confirm how the Division wants the signed agreement delivered. Sign it, initial both acknowledgments and fill in every payment detail before you send it. FillingPDF lets you fill out and download the PDF; submission follows the Division's channels.
Common mistakes to avoid
- Leaving out the initials next to either acknowledgment; the form says you must acknowledge each statement by placing your initials next to it.
- Planning payments that will not clear the full balance within 24 months of the agreement date; the form caps the repayment period at six months, not to exceed 24 months.
- Leaving interest and penalty out of the total; the promise covers the total listed plus the interest and penalty that will accrue.
- Treating the agreement as covering future contributions; it pertains only to the outstanding debt it lists, and you agree to stay current on later obligations.
- Missing payments under the schedule; this voids the agreement and may lead to a distress warrant and/or a judgment filed in Small Claims Court.
- Expecting a lien to be lifted after partial payments; the form says a lien is released only when contributions, interest, penalty and negative interest are paid in full.
- Leaving the first-payment amount and date, the monthly amount or the day of the month blank in the promise paragraph.
- Signing without a title, printed name, date, email or phone number, all of which the signature block asks for.
Frequently asked questions
What is the Form 10 payment agreement in South Dakota?
Form 10, Payment Agreement, is a South Dakota Department of Labor and Regulation form in which an employer acknowledges a debt to the Reemployment Assistance Division and promises to repay it with a first payment followed by monthly payments. The debt is listed by quarter and year.
How long can I take to pay under the payment agreement?
The agreement requires full payment, including the interest and penalty that accrue, within six months and not more than 24 months from the date of the agreement. The promise paragraph sets the first payment date and the day of each month for later payments.
What happens if I miss a payment on the agreement?
Failing to follow the payment agreement voids it. The form states this may result in the issuance of a distress warrant and/or a judgment filed in Small Claims Court, so the whole debt can then be pursued without the schedule.
Can the Department file a lien on my business under this agreement?
Yes, the form says the Department of Labor and Regulation may file a lien for the total amount due. A lien is released only once contributions, interest, penalty and negative interest are paid in full, not after partial payments.
Does the payment agreement cover contributions I owe in the future?
No. The agreement pertains only to the outstanding debt listed in it. By initialing the second statement you also agree to stay current on any future obligations to the Department of Labor and Regulation.
Do interest and penalty keep growing while I pay?
Yes. The form says interest is assessed on the first day of each month on unpaid contributions and that additional penalty charges may be assessed. Your promise covers the listed total plus interest and penalty that accrue; ask the Division for current figures.
Where do I send the completed payment agreement?
The form prints no return instruction. Its header lists the Reemployment Assistance Division at PO Box 4730, Aberdeen, SD 57402-4730, phone 605.626.2312 and fax 605.626.3347. Call the Division to confirm how it wants the signed form delivered.
Can I fill out the payment agreement online?
You can fill out the Form 10 PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not file or send the agreement to the Division; you deliver it through the Division's channels.
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