Form Cli001f - Unemployment Insurance Claim Application Page 2
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4ID or SSN:
Last Name:
Mailing Address
*Country: (Check one)
U.S. (Includes U.S. Territories)
Canada
Other
In Care of:
*Address:
*Apt / Unit#:
*City:
*State:
*Zip Code:
+
*County:
Primary Telephone: (
)
-
Secondary Telephone: (
)
-
*P.O. Box?
Yes
No
*If yes, provide the reason your mail is to be sent to a P.O. Box.
Residential Address
(A Residential Address must be provided if you are using a P.O. Box or are living at an address that is different than your
Mailing Address)
* Do you have a residential address that is different than your mailing address?
Yes
No
(If no, skip to Border State)
*Country: (Check one)
U.S. (Includes U.S. Territories)
Canada
Other
In Care of:
*Address:
*Apt / Unit#:
*City:
*State:
*Zip Code:
+
*County:
Office Use Only: Retire this address in favor of mailing record?
Yes
No
Border State
(If you do not live in a Border State, skip to Tax Information)
Wisconsin, Indiana, Kentucky, Missouri, and Iowa
* Have you performed work in Illinois at any time during the last 18 months while living in a border state?
Yes
No
* Do you plan on looking for work in IL?
Yes
No
* Are you temporarily laid off for 10 weeks or less from an Illinois employer?
Yes
No
Tax Information
(Illinois residents only)
* I elect to have Federal Income Tax withheld from my gross Unemployment Insurance Benefit
Yes
No
payments in the amount of 10 %
* I elect to have Illinois State Income Tax withheld from my gross Unemployment Insurance Benefit
Yes
No
payments in the amount of 4.95%
Citizenship
Yes
No
* Are you a citizen of the United States?
(If yes, skip to the General Information Area)
* Are you authorized to work in the United States?
Yes
No
/
/
* Alien Registration Number:
* Entrance Date
* Expiration Date:
* Document Type:
/
/
Office Use Only: Initial Verification with Homeland Security
Yes
No
Secondary verification required
Yes
No
Homeland Security Information Validated
Yes
No
Homeland Security Verification Number:
General Information
(Check one in each section unless otherwise indicated)
English
Bosnian/Serbian/Croatian
Yes
No
Prefer not to answer
*Disability:
Spanish
Italian
*Language:
Polish
Korean
*Gender:
Male
Female
Prefer not to answer
(Preference)
Cantonese
Portuguese
Vietnamese
Tagalog
*Ethnicity:
Hispanic or Latino
Arabic
Sign Language
Not Hispanic or Latino
Russian
German
Prefer not to answer
Hindi
TTY
Mandarin
Other
CLI001F
Page 2 of 4
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Parent category: Legal