Form Ui-28 - Employer'S Claim For Adjustment / Refund - Illinois Department Of Employment Security - 2013

Download a blank fillable Form Ui-28 - Employer'S Claim For Adjustment / Refund - Illinois Department Of Employment Security - 2013 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Ui-28 - Employer'S Claim For Adjustment / Refund - Illinois Department Of Employment Security - 2013 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

UI-28
STATE OF ILLINOIS
(Do Not Use)
DEPARTMENT OF EMPLOYMENT SECURITY
Stock # 7189 IL 427-0235
REVENUE DIVISION
(Rev. 1/13)
DDCN No.
33 SOUTH STATE STREET, CHICAGO, ILLINOIS 60603
Fax number:
312-793-4351
EMPLOYER'S CLAIM FOR ADJUSTMENT / REFUND
Please read the instructions for this form. If you are adjusting individual worker's wages, you must complete Form UI-28B, the
Employer's Correction Report of Wages Paid to Workers, and submit it with this form.
Employer Name
Account No.
Doing Business As
Address
(Street) (City) (State) (Zip Code) (Contact Phone Number)
E-mail Address
Fax Number
This claim is filed for an adjustment/refund of erroneously paid contributions, interest and/or penalty thereon based on the facts
presented here and in the amount shown below.
(If more space is required, attach additional sheets.)
A. BASIS OF CLAIM:
(Enter the year applicable to your claim. Prepare a separate claim for each calendar year.)
B. FOR THE YEAR ________
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
C. COMPUTATION:
Reported
As Corrected
Reported
As Corrected
Reported
As Corrected
Reported
As Corrected
1. Total Wages
2. Less Wages in
Excess
of $
3. Taxable Wages
4. Taxable Wages
Overstated
5. Contributions
Overpaid
6. Interest
Overpaid
7. Penalty
Overpaid
8. Total Overpaid
(by quarter)
9. TOTAL AMOUNT OF THIS CLAIM ........................................................................................... $
The undersigned states that the information contained in this claim, including Form UI-28B and any other attachments, is true and correct to the
best of their knowledge and belief and that no claim for this erroneous payment has previously been made.
This state agency is requesting disclosure of information that is necessary
Signed by
to accomplish the statutory purpose as outlined under 820 ILCS 405/2201.
Disclosure of this information is voluntary. However, failure to use this form
Official
Date
in applying for a refund will result in your refund request being denied
Title
This claim for refund MUST be signed by owner, partner, officer or authorized agent
within the employing enterprise. If signed by any other person, a Power of Attorney
(DO NOT USE SPACE BELOW)
must be on file.
Verified Facts & Figures
Total Amt. Allowed:
$
$
Approved as to Law
Less Amt. Applied:
$
Denied
Net Credit:
$
Approved
Net Refund:
Reviewed

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Ui-28 - Employer's Claim For Adjustment/refund - Illinois Department Of Employment Security Form Ui-28 - Employer's Claim For Adjustment/refund - Illinois Department Of Employment Security Legal
Form Ui-28 - Employer's Claim For Adjustment/refund - Illinois Form Ui-28 - Employer's Claim For Adjustment/refund - Illinois Legal
Form Ui-28 - Employer's Claim For Adjustment/refund Form Ui-28 - Employer's Claim For Adjustment/refund Financial
Form Ui-28 - Employer's Claim For Adjustment / Refund - 2017 Form Ui-28 - Employer's Claim For Adjustment / Refund - 2017 Legal
Instructions For Preparation Of Form Ui-28, Employer's Claim For Adjustment / Refund Instructions For Preparation Of Form Ui-28, Employer's Claim For Adjustment / Refund Legal
Instructions For Form Ui-28 - Employer's Claim For Adjustment/refund Instructions For Form Ui-28 - Employer's Claim For Adjustment/refund Financial
Form 1099-ltc - Long-term Care And Accelerated Death Benefits - Department Of The Treasury - 2013 Form 1099-ltc - Long-term Care And Accelerated Death Benefits - Department Of The Treasury - 2013 Financial
Form Mdes 1d-ar - Employer's Quarterly Wae Detail Report - Minnesota Department Of Economic Security Form Mdes 1d-ar - Employer's Quarterly Wae Detail Report - Minnesota Department Of Economic Security Legal
Employer's Unemployment Quarterly Tax Report - Minnesota Department Of Economic Security Employer's Unemployment Quarterly Tax Report - Minnesota Department Of Economic Security Financial
Form Mdes 1d - Employer's Quarterly Wage Detail Report - Minnesota Department Of Economic Security Form Mdes 1d - Employer's Quarterly Wage Detail Report - Minnesota Department Of Economic Security Financial

Related Categories

Parent category: Legal
Download
Go