Form Cli001f - Unemployment Insurance Claim Application Page 3
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4ID or SSN:
Last Name:
*Dependent Type: (check all that apply)
Spouse
Dependent Under 18
Dependent Over 18 (& unable to work due to illness/disability)
None
*Race: (check all that apply)
White
Black/African American
American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
Prefer not to answer
*Education
Provide the highest level of education by checking one:
00
(no school grade completed)
1
2
3
4
5
6
7
8
9
10
11
12
GED
H.S. Diploma
(completed, did not graduate)
1
Yr College, Tech. or Voc. School
st
2
Yr College, Tech. or Voc. School
Vocational/Technical Degree or Certificate
nd
Associates Degree
3 yrs College, Tech. or Voc. School
Bachelor’s Degree or Equivalent
Education Beyond Bachelor’s
Master’s
Doctorate
MD-Doctor of Medicine
JD-Doctor of Law
*Veteran Information
Have you served on active duty on the U.S. Armed Forces for more than 180 days
Yes
No
NOT including training for the National Guard or Reserves and were issued a DD214?
Yes
No
*Are you a spouse of a Veteran injured, disabled or killed in the line of duty?
(If you selected no to both questions, skip to Payment Method)
/
/
/
/
*Branch of Service
*Start Date
*End Date
*Do you have a service connected disability?
*If yes, what % is your disability currently rated?
Yes
No
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
(Check one)
*Are you homeless?
*Do you have a campaign medal?
Yes
No
Yes
No
*Was your discharge Dishonorable?
Yes
No
Direct Deposit (Request an Authorization Form)
Debit Card
*Payment Method Information
(Check one)
Note: If you choose Direct Deposit, payment will be made by Debit Card until your Direct Deposit request is Authorized.
Dependent Detail
(If you do not wish to claim dependents skip to Employment History)
*Dependent Type: Child (Include natural children, stepchildren, legally adopted children and children of whom you have court ordered custody) Do
you have children under the age of eighteen OR an older child who was unable to work during the past 90 days due to an illness or disability?
Yes
No
(If no, skip to Dependent Type: Spouse)
*Number of Dependent Children Under 18:
(Provide the name, SSN and birth date starting with your youngest child)
*First Name
MI
*Last Name
SSN
*Date of Birth
If you have more than two dependent children under 18, request Dependent Listing Form.
*Dependent Child Over 18 with Illness/Disability: (Provide the name, SSN and birth date of your dependent child over 18)
*First Name
MI
*Last Name
SSN
*Date of Birth
*What is the illness or disability?
If you have more dependent children over 18 with illness or disability, request Dependent Listing Form.
1a) *Do you and the children’s other parent live in the same household? (If no, skip to question 2)
Yes
No
1b) *Did you and your spouse together provide more than 50% of the support of the children during the past 90 days and did you
provide at least 25% of that support?
Yes
No
2) *If you and the children’s other parent do not live in the same household, did you furnish more than 50% of the support for
the children during the past 90 days?
Yes
No
3) *Within the past 12 months, up to today, has anyone else claimed any of your children on an Illinois Unemployment
Yes
No
Insurance Claim?
If Yes, what is the name and SSN of the person claiming the dependant child/children?
/
/
*Name:
*SSN:
*Dependent Type: Spouse (or civil union partner) *SSN:
/
/
Date of Birth:
/
/
*First Name:
MI:
*Last Name:
*Within the past 18 months did your spouse work in Illinois?
Yes
No
*For the 90 consecutive days before this claim, did you furnish more than 50% of the cost of
Yes
No
support for your lawful spouse?
CLI001F
Page 3 of 4
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