Employer’s Report of Wages Paid To Each Worker 
                                                                                                                                                            -- Continuation Sheet

                                                 Fax: 217-557-1948
ACCOUNT NUMBER _________________________________                                                                                                                                                                                                         Date                                                                     Page 
                                                                                                                                                                                                                   Quarter                                                                                                  Number
                                                                                                                                                                                                                   Ended
                                                                                                                                                                                                                                                                                                                                                        PLANT CODE
                                                                                                                                                                                                                   READ INSTRUCTIONS
                                                                                                                                                                                                                   Double space if possible.
                                                                                                                                                                                                                                                                                                                                       No. _____________
                                                                                            Enter here employer’s name, address and Illinois Unemployment                                                          FORM UI-3/40 MUST accompany this form.
                                                                                            Insurance Account No. exactly as shown on top of Form UI-3/40.

                                                     Workers Social Security                                                                                             NAME OF WORKER                                                                                                          TOTAL Wages Paid
                                                                             Account Number                                                                                             (Type or Print)                                                       (Include Non-Taxable Wages)
                                                                                                                                                          8                                             9                                                                                                        10
                                                                             -00-0000000                                                                    (First and Initial)                           (Last)                                                                         Dollars                       Cents

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                                                 11.  ...................................................................................Total Wages Listed on this Page                                         $                                                                                               $ 0.00

08UI-40A/17)                                         (Rev 

                                                                                                                                       INSTRUCTION FOR FORM UI-40A
                                                                                                                                                                  (Continuation Sheet)

(1)                                                                   This continuation Sheet, Form UI-40A, is provided for use when
                                                                      additional space is required to complete Form UI-3/40. The origi-
                                                                      nal Continuation Sheet should be securely attached to the upper
                                                                      left corner of the Form UI-3/40.

(2) The Continuation Sheets for each return should be numbered con-
                                                                      secutively, beginning with Page Number 2. Form UI-3/40 is
    regarded as Page Number 1.

(3)                                                                   The employer’s name, address, and account number should be
    entered in the space provided at the top of each sheet. These par-
    ticulars should be the same as shown at the top of Form UI-3/40.