Form Le-10 - Power Of Attorney For Representing Employer/form Ui-1m - Unemployment Insurance Special Mailing Form Page 2
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2UI-1M (Rev. 01/01)
STATE OF ILLINOIS
DEPARTMENT OF EMPLOYMENT SECURITY
401 SOUTH STATE STREET
CHICAGO, ILLINOIS 60605-1229
UNEMPLOYMENT INSURANCE SPECIAL MAILING FORM
The purpose of this form is to notify the Department of a request to have correspondence sent to an address other than your
business address or to terminate a preexisting address. If the requested address being added is for a third party or
service bureau, you must also complete the Power of Attorney (LE-10) form.
Employer Name
DBA Name
Illinois UI Account Number
Federal I.D. Number
Note: Each form can be directed to only one address. Therefore, check only once for each form. If your request cannot be
contained in its entirety on this form because of multiple addresses, please provide additional copies of the form:
____ BIS-32 (Notice to Chargeable Employer)
C/O (Name of Representative or Service Bureau)
____ UI-3/40 (Contribution & Wage Report)
____ Ben 118/118R (Benefit Charge Notice)
Street Address
Unit or Suite
____ UI-5A/UI-5B (Rate Notice)
____ Benefit Appeal Notice
____ SI-5 (Notice of Benefit Earnings Audit)
City
State
Zip Code
Country
Telephone Number
Effective Date
Termination Date
____ BIS-32 (Notice to Chargeable Employer)
C/O (Name of Representative or Service Bureau)
____ UI-3/40 (Contribution & Wage Report)
____ Ben 118/118R (Benefit Charge Notice)
____ UI-5A/UI-5B (Rate Notice)
Street Address
Unit or Suite
____ Benefit Appeal Notice
____ SI-5 (Notice of Benefit Earnings Audit)
City
State
Zip Code
Country
Telephone Number
Effective Date
Termination Date
Signed by
Date
Title
Telephone Number
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