Form Ui-3/40 - Employer'S Contribution And Wage Report Form - 2003
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2EMPLOYER’S CONTRIBUTION AND WAGE REPORT
STATE OF ILLINOIS Department of Employment Security
Page No. 1 of ________ Pages
401 South State Street, Chicago, IL 60605
Do Not include wage corrections for a prior quarter in this report.
(Employers with 250 or more employees in the previous calendar year must file via magnetic media.)
Worker’s Social Security
NAME OF WORKER
TOTAL Wages Paid
Account Number
(Type or Print)
(Include Wages in
Name
Excess of $9,000)
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.
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 $9,000 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
report and in all accompanying schedules is true and
This agency is requesting both disclosure of
correct to the best of my knowledge and belief; and
information and payment of contributions that are
that no part of the contribution reported was or is to
necessary to accomplish the statutory purpose as
be deducted from workers’ wages.
outlined under 820 ILCS 405/100-3200. Disclosure
Signed ...........................................................
of information and payment of contributions are
Title ...............................................................
REQUIRED. Failure to provide information or pay
(
AREA
)
contributions may result in this form not being
CODE
Telephone .......................................................
processed and may result in statutorily prescribed
Date ..............................................................
sanctions, including penalties and/or interest.
This report MUST be signed by owner, partner, officer
or authorized agent within the employing enterprise.
$
(See Instructions)
11. TOTAL WAGES FOR THIS QUARTER
UI-3/40 (Rev. 01/03)
IL 427-0018 Stock No. 4601
Printed on Recycled Paper
If more space is needed to list workers, use continuation sheets, Form UI-40A.
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