Form Ui-28b - Employer'S Correction Report Of Wages Previously Reported - 2009

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Revenue Division
State of Illinois
33 South State Street, 10
Floor
th
Department of Employment Security
Chicago, Illinois 60603-2901
Employer's Correction Report of Wages Previously Reported
(Do not use this space)
Note: This form is to be used only for itemized information of individual wage reports affected by claim for refund.
ASSIGNMENT NO.______________________
Employer Name
Account No.
Address
This claim covers the year of _________ ONLY, on a calendar quarter basis.
Worker's Social
Quarter Ending 3-31
Quarter Ending 6-30
Security Number
Total Wages
Total Wages
Excess As
Excess As
Total Wages
Total Wages
Exc ess As
Excess As
Name of Worker
Originally Reported
As Corrected
Reported
Corrected
Originally Reported
As Corrected
Reported
Corrected
Totals on This Page
Totals on All Pages
(SEE PAGE 2 FOR QUARTERS ENDING 9-30 AND 12-31)
(SEE INSTRUCTIONS ON PAGE 3)
Page 1 of 3
UI-28B (REV. 08/2009)

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