Employer's Correction Report 
                                     for the Quarter Ending: 

Fax:  217-557-1948                   Revenue Division - 307 E. Jackson Street, 3rd Floor 
Phone:  800-247-4984                 Springfield, Illinois 62701 

ACCOUNT NUMBER:                                                                     SPECIAL INSTRUCTIONS 
                                                                           1. Prepare a separate correction report for each quarter. Retain a copy for your files. 
                                                                           2. Give complete explanation. 
                                                                           3. Always complete Schedule A. 
                                                                           4. Be sure to complete Schedule B if you are correcting wages reported for individual 
                                                                           workers. 
Enter complete account number, name and address in the space above. 

SCHEDULE A - QUARTERLY WAGE INFORMATION                                    EXPLANATION 
                            As Reported on UI-3/40 Should Be 
Line 2. Total Wages Paid 
Line 3. Less: Excess Wages 
Line 4. Taxable Wages 
Line 5. Contribution Due 

NOTE:  The taxable wage base is subject to change annually.  Please refer to your original quarterly wage report (form UI-3/40) for the 
wage base of the year  you  are correcting. 

                                     SCHEDULE B - INDIVIDUAL WAGE CORRECTIONS 
                      LIST ONLY THOSE WORKERS WHOSE WAGES ARE TO BE CORRECTED 
Worker's Social Security                                                            UI-3/40                           W  A  G  E  S 
     Account Number                         Worker's Name (Type or Print)           Page #                As Reported Should Be 

                                                                                    TOTAL 

I certify that the information in the foregoing report is true and correct to the best of my knowledge and belief. 

Date ________________________________________                        Signed ___________________________________________________ 

This report MUST be signed by owner, partner, officer, or authorized Title ______________________________________________________ 
agent within the employing enterprise. If signed by any other person,
a Power of Attorney must be on file. 

UI-40C (Rev.04/24)