Form Ui-3/40 - Employer'S Contribution And Wage Report Form - 2003 Page 2
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2UI-40A (Rev 5/98)
ILLINOIS
IL 427-0380
EMPLOYER’S REPORT OF WAGES PAID TO EACH WORKER
Department of Employment Security
Stock No. 4292
CONTINUATION SHEET
DIVISION OF REVENUE
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 _____________________________________________
$
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