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: For calendar year V201                    ,  and 2017  the taxable wages of $12,9 0 of wages paid to each worker for the calendar year. For 
the calendar year       WD[DEOH ZDJHV DUH WKH ILUVW         RI ZDJHV SDLG WR HDFK ZRUNHU IRU WKH FDOHQGDU \HDU  

                                    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. 11 7/1 )
IL 427-0406
Stock No. 7192