Form U1-1 - Report To Determine Liability Under The Unemployment Insurance Act - 2003 Page 2

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If you answered question 8 or answered yes to question 9, proceed to question 13. Otherwise proceed to question 10.

10. a. Have you had an ILLINOIS payroll totaling $1500 or more in any calendar quarter during the current or preceding four years?

________ YES ________ NO.

If YES, indicate the first year with a quarterly payroll of $1500 or more __________

b. Circle the quarter and enter the total wages paid in that quarter: January - March $ _______________ April - June $ _______________

July - September $_______________ October - December $ _______________

c. Do you expect to have an Illinois payroll of $1500 or more during the current calendar quarter?________ YES ________ NO

11. a. Have you employed 1 or more workers in ILLINOIS within each of 20 or more calendar weeks during the current or preceding four years

(weeks need not be consecutive)? ________ YES ________ NO.

b. If YES, indicate the first year with 20 or more calendar weeks of employment _______________ .

Circle the quarter in which that 20th week occurred:

April-June

July-Sept.

Oct.-Dec.

12.

Have you incurred liability under the Federal Unemployment Tax Act (in any state) for any of the last 5 years? ________ YES ________ NO

If YES, indicate the year(s) of such liability _____________________________________________________________________________________

13.

Are there any persons not included in questions 11 or 12 who performed services for you, as an independent contractor or otherwise, received compensation

of any kind from you or operated within your business establishment? ________ YES________ NO. If YES attach a sheet stating the number of such

persons and give details as to the type of service and the date such services were performed.

............................................................................................................................................................................................................................................

14.

Complete the following section only if you have multiple worksites in Illinois.

The following information is required for reporting of statistical data to the federal government. Please complete the information as completely and

accurately as possible.

Enter below the required information for each place of business (worksite) in Illinois (use additional sheets if necessary). Read instructions carefully. If any

worksite is engaged in performing support services for other units of the company, please indicate the nature of the activity in “section c-Primary Activity”.

Examples of Support Services are: Central Administrative Office, Research, Development or Testing, Storage (warehouse). See instructions for additional

examples.

Physical Location of Each

County

Primary Activity

Average No. of Employees

Establishment (Street, city, zip code)

15.

If you are determined not liable, based upon the provisions of the Unemployment Insurance Act, you may voluntarily elect coverage under Section 205(h).

Please indicate whether you want voluntary coverage ________ YES. If checked, we will mail you form UI-1B, VOLUNTARY ELECTION OF

COVERAGE. Please complete that form and return it to this Department.

CERTIFICATION: I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THIS REPORT AND ANY SHEETS ATTACHED HERETO IS

TRUE AND CORRECT. THIS REPORT MUST BE SIGNED BY OWNER, PARTNER, OFFICER OR AUTHORIZED AGENT WITHIN THE EMPLOYING ENTERPRISE.

IF SIGNED BY ANY OTHER PERSON, A POWER OF ATTORNEY MUST BE ATTACHED. A POWER OF ATTORNEY FORM IS INCLUDED IN THIS PACKET.

Employer Name __________________________________________________________________________________________________________________

Signed by ________________________________________________________________________ Date _________________________________________

Title ____________________________________________________________________________________________________________________________

.... DO NOT WRITE IN THE AREA BELOW. FOR DEPARTMENT USE ONLY ....

This state agency is requesting

SOURCE ____________ REC’D DATE _______

information that is necessary to