Form Ui-3/40 - Employer'S Contribution And Wage Report - 2012
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1
2EMPLOYER’S CONTRIBUTION AND WAGE REPORT
STATE OF ILLINOIS Department of Employment Security
Page No. 1 of ________ Pages
33 South State Street, Chicago, IL 60603-2802
Do Not include wage corrections for a prior quarter in this report.
(Employers with 25 or more employees in the previous calendar year must file via electronic media.)
Please Return This Sheet to PO Box 19300, Springfield, Illinois 62794.
Worker’s Social Security
NAME OF WORKER
TOTAL Wages Paid
Name
Account Number
(Type or Print)
(Include wages in excess of
taxable wage base amount)
Address
8.
9.
10.
City, State Zip
000
00
0000
Dollars
Cents
-
PENALTY ($50 MIN.)
INTEREST DUE
ILLINOIS ACCOUNT NUMBER
YR. / QTR.
QUARTER ENDING
(SEE 6B)
(SEE 6A)
Your Federal Employer Identification Number
CHANGE IN STATUS
If a change has occurred in the status of your business, complete form UI-50A.
Check this box to indicate that you no longer have workers in Illinois and want your account terminated. Also, complete the UI-50A.
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. If none, enter “0”.
1st Month _______________ 2nd Month _______________ 3rd Month _______________
2. TOTAL WAGES PAID for covered employment
IMPORTANT — SEE INSTRUCTIONS
3. LESS WAGES in excess of the taxable wage base amount per covered worker.
4. TAXABLE WAGES ( line 2 minus line 3 )
Use this space if TOTAL WAGES (line 2) are less than $50,000 this quarter
5A. CONTRIBUTION DUE
Use this space if TOTAL WAGES (line 2) are $50,000 or more this quarter
5B. CONTRIBUTION DUE
6A. Add Interest at 2% ( .02) per month for late payment
6B. Add Penalty for late filing ( $50.00 minimum )
6C. Add Previous Underpayment PLUS interest
6D. Deduct Previous Overpayment
7. TOTAL PAYMENT DUE
MAKE CHECK PAYABLE TO:
DIRECTOR OF EMPLOYMENT SECURITY
(If Less than $2.00 — Send Report Only)
I hereby certify that the information contained in this
This agency is requesting both disclosure of
report and in all accompanying schedules is true and
information and payment of contributions that are
correct to the best of my knowledge and belief; and
necessary to accomplish the statutory purpose as
that no part of the contribution reported was or is to
outlined under 820 ILCS 405/100-3200.
be deducted from workers’ wages.
Disclosure of information and payment of
Signed ...........................................................
contributions are REQUIRED. Failure to provide
information or pay contributions may result in this
Title ...............................................................
form not being processed and may result in
(
AREA
)
statutorily prescribed sanctions, including
CODE
Telephone .......................................................
penalties and/or interest.
Date ..............................................................
This report MUST be signed by owner, partner, officer or authorized agent within the employing enterprise.
If signed by any other person, a Power of Attorney must be on file.
(See instructions)
11. TOTAL WAGES FOR THIS QUARTER
$
UI-3/40 (Rev. 01/12)
IL 427-0018
If more space is needed to list workers, use continuation sheets, Form UI-40A.
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