Instructions:

Please call and make an appointment with a Revenue agent to audit your loss claim.

Aberdeen (605)626-2218; Mitchell (605)995-8080; Pierre (605)773-3311; Rapid City (605)394-2332; Sioux Falls (605)367-5800; Watertown (605)882-5188; or Yankton (605)668-2939

Your Revenue Agent will confirm the can, case or bottle count only. The both of you will then sign and date the form. This completed form will be emailed by the Revenue Agent to SpecialT@state.sd.us.

Please check that you agree before continuing.

By continuing I agree that I am willing to complete a digital version of the document(s) and that information about my user session will be stored.

Create Your Signature

Please fill in your name and email and then either draw or type your signature below.

Full Legal Name

Your Initials

Signature Type

Type Draw Upload Custom

Clear Signature

Signature will be applied to the page. You will have a chance to review after signing.

Check this box to continue

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Additional Signatures Required

South Dakota Department of Revenue

Print Document

Create Your Signature

Sign Now!

Please provide accurate information below to ensure the delivery of the signed copies of the document.