Ides Low Earnings Report (Ben-25) Form

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IDES LOW EARNINGS REPORT (BEN-25)
Calendar Week
Gross Wages
Social Security Number
First Name
Initial
Last Name
Holiday Pay
Ended
Earned
FOR CLAIMANTS USE -- See Instructions
EMPLOYER -- Enter firm name and address in the space. See
instructions.
I hereby certify that during the CALENDAR week ending on the
date shown above (or on attached valid evidence), I was employed
I certify that during the CALENDAR week ending on the date
less than full time and did not earn more than the gross wages
shown above the worker named worked less than full time and that
shown above; I was able to and available for work and did not
his earnings were reduced to the amount shown above because of
refuse work; I did not claim or receive workmen's compensation for
LACK OF WORK except as stated below.
temporary disability, unemployment compensation from any other
state or under any Act of Congress, or a pension, any part of which
was paid for by a former employer. I know that the law imposes
Unable to work or unavailable for work on ____________
penalties for making any false statement in connection with this
claim.
By ______________________________________________
Title ____________________________________________
Sign Here (X)
Date Given to Worker ______________________________
Address
UI (ILL) BEN-25 (Rev. 3/93)
For Office Use Only - Do Not Write Below This Line
IL 427-0392
Stock No. 4029
LOW EARNINGS REPORT
Printed on Recycled Paper
Department of Employment Security - Unemployment Insurance

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