Form Ui-3/40 - Employer'S Contribution And Wage Report - 2017
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1
2EMPLOYER’S CONTRIBUTION AND WAGE REPORT
Do NOT staple reports or payment.
This report & payment can be mailed to: IDES, PO Box 19300, Springfield, IL 62794-9300
Employers that have less than 25 employees have the option of using
Page No. 1 of_____Pages
this form. If the employer has 25 or more employees, the employer
Do NOT include wage corrections
must file electronically.
STATE OF ILLINOIS
Department of Employment Security
for a prior quarter in this report.
FORM UI-3/40 Rev. 3/2017
UCONTRIBUTION RATE FOR
D.C. NO.
8.
Worker’s Social Security
9.
NAME OF WORKER
10.
TOTAL Wages Paid
Account Number
(First and initial)
(Type or Print)
(Last)
(Include Wages in
Excess of $12,960)
L07ZZZZZZZ
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000
00
0000
Enter Dollars & Cents:
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Save
00/00
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R
9999999
9 20062 L10ZZ-2006
PENALTY ($50.00 MIN.)
INTEREST DUE
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ILLINOIS
ACCOUNT NUMBER
CK
YR/QTR
PERIOD ENDING
DUE AFTER ABOVE DATE
AFTER ABOVE DATE
Print
00-0000000
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Your Federal Employer Identification Number
L09ZZZZZZZ
(If not shown or if incorrect enter correct number)
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Clear
CHANGE IN STATUS
If a change has occurred in the status of your business, complete form UI-50A.
I I
Check this box to indicate that you no longer have workers in Illinois and want your account terminated.
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Also, complete form UI-50A.
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1.
ENTER THE TOTAL NUMBER OF COVERED WORKERS
(full and part time) who performed services
during or received pay for the payroll period including the 12th of each month of the quarter.
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If none, enter “0”.
1ST MONTH________________2ND MONTH_________________3RD MONTH______________
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. .
2. TOTAL WAGES PAID for covered employment
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(If no wages were paid, see instructions.)
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IMPORTANT — SEE INSTRUCTIONS
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3. LESS: Wages in excess of
$12,960
per covered worker per calendar year.
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4. TAXABLE WAGES (line 2 minus line 3)
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5A. If the quarter’s TOTAL WAGES (Line 2) are less than $50,000,
. .
calculate at the lessor of your rate as shown on your "Annual Contribution
Rate Determination" or 5.4%.
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. .
or more this quarter.
Use this space if TOTAL WAGES (Line 2) are
$50,000
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5B. CONTRIBUTION DUE - Multiply line 4 by your rate.
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6A. Add: Interest at 2% (.02) per month for late payment
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6B. Add: Penalty for late filing ($50.00 minimum)
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6C. Add: Previous Underpayment PLUS interest
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6D. Deduct: Previous Overpayment
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7. TOTAL PAYMENT DUE
MAKE CHECK PAYABLE TO:
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“ILLINOIS DIRECTOR OF EMPLOYMENT SECURITY”
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(If less than $2.00 - Send report only)
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I hereby certify that the information contained in
this report and in all accompanying schedules is
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true and correct to the best of my knowledge and
This agency is requesting both disclosure of
belief; and that no part of the contribution reported
information and payment of contributions that
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was or is to be deducted from workers’ wages.
are necessary to accomplish the statutory
purpose as outlined under 820 ILCS 405/100-
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Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3200. Disclosure of information and payment
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Title . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
of contributions are REQUIRED.
Failure to
(
)
AREA
provide information or pay contributions may
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CODE
Telephone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
result in this form not being processed and
may result in statutorily prescribed sanctions,
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Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
including penalties and/or interest.
0.00
This report MUST be signed by owner, partner,
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11. Total Wages
$. . . . . . . . . . . . . . . . . . . . . . . . . .
officer or authorized agent within the employing
enterprise. If signed by any other person, a Power
of Attorney must be on file.
(See Instructions)
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