Form Ui-3/40 - Employer'S Contribution And Wage Report - 2017 Page 2
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Employer’s Report of Wages Paid To Each Worker
Clear
-- Continuation Sheet
Date
Page
ACCOUNT NUMBER _________________________________
Quarter
Number
Ended
PLANT CODE
READ INSTRUCTIONS
Double space if possible.
No. _____________
Enter here employer’s name, address and Illinois Unemployment
FORM UI-3/40 MUST accompany this form.
Insurance Account No. exactly as shown on top of Form UI-3/40.
Workers Social Security
NAME OF WORKER
TOTAL Wages Paid
Account Number
(Type or Print)
(Include Non-Taxable Wages)
8
9
10
000-00-0000
(First and Initial)
(Last)
Dollars
Cents
11. Total Wages Listed on this Page ...................................................................................
$ 0.00
$
UI-40A (Rev 03/17)
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