Form Ui-28 - Employer'S Claim For Adjustment / Refund - 2017
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1UI-28
STATE OF ILLINOIS
(Do Not Use)
DEPARTMENT OF EMPLOYMENT SECURITY
Stock # 7189 IL 427-0235
REVENUE DIVISION
(Rev. 2/17)
DDCN No.
33 SOUTH STATE STREET, CHICAGO, ILLINOIS 60603
Fax number:
312-793-4351
EMPLOYER'S CLAIM FOR ADJUSTMENT / REFUND
Please read the instructions for this form. If you are adjusting individual worker's wages, you must complete Form UI-28B, the
Employer's Correction Report of Wages Paid to Workers, and submit it with this form.
Employer Name
Account No.
Doing Business As
Address
(Street) (City) (State) (Zip Code) (Contact Phone Number)
E-mail Address
Fax Number
This claim is filed for an adjustment/refund of erroneously paid contributions, interest and/or penalty thereon based on the facts
presented here and in the amount shown below.
(If more space is required, attach additional sheets.)
A. BASIS OF CLAIM:
(Enter the year applicable to your claim. Prepare a separate claim for each calendar year.)
B. FOR THE YEAR ________
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
C. COMPUTATION:
Reported
As Corrected
Reported
As Corrected
Reported
As Corrected
Reported
As Corrected
1. Total Wages
2. Less Wages in
Excess
of $
3. Taxable Wages
4. Taxable Wages
Overstated
5. Contributions
Overpaid
6. Interest
Overpaid
7. Penalty
Overpaid
8. Total Overpaid
(by quarter)
9. TOTAL AMOUNT OF THIS CLAIM ........................................................................................... $
The undersigned states that the information contained in this claim, including Form UI-28B and any other attachments, is true and correct to the
best of their knowledge and belief and that no claim for this erroneous payment has previously been made.
This state agency is requesting disclosure of information that is necessary
Signed by
to accomplish the statutory purpose as outlined under 820 ILCS 405/2201.
Disclosure of this information is voluntary. However, failure to use this form
Official
Date
in applying for a refund will result in your refund request being denied
Title
This claim for refund MUST be signed by owner, partner, officer or authorized agent
within the employing enterprise. If signed by any other person, a Power of Attorney
(DO NOT USE SPACE BELOW)
must be on file.
Verified Facts & Figures
Total Amt. Allowed:
$
$
Approved as to Law
Less Amt. Applied:
$
Denied
Net Credit:
$
Approved
Net Refund:
Reviewed
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