State of Illinois
Department of Employment Security
Retirement/Pension Pay Questionnaire - Employer
ADJ006FE Page 1 of 1 QU27CE Rev. (09/2011)
Claimant Information:
Last Name: First Name: MI:
SSN: Employer Account #:
Under Section 611 of the Illinois Unemployment Insurance Act, receipt of retirement pay is considered disqualifying income
and may be deducted from the claimant’s benefits. Please provide information about this payment to determine the claimant’s
eligibility for Unemployment Insurance Benefits.
Please complete, sign and return this questionnaire to the Illinois Department of Employment Security Office as instructed. If
you need additional space, please use the other side of this document, if appropriate, or attach a separate sheet of paper.
This state agency is requesting information that is necessary to accomplish the statutory purpose as outlined in 820 ILCS
405/100-3200. Disclosure of this information is voluntary. However, failure to disclose this information may result in the
erroneous payment of Unemployment Insurance benefits which may affect the amount of your liability for contributions or
payments in lieu of contributions.
Thank you for your cooperation in this matter.
Section A: Retirement/Pension Information
Did the claimant make contributions toward the retirement? Yes No
Did you make contributions toward the retirement? Yes No
What type of payment does the claimant receive or has he/she applied for? (Select one)
Retirement Pension/Annuity Federal, Military or Railroad
Profit Sharing State or Local Government outside of Illinois
How is the retirement/pension paid? (Select one)
One time lump sum
(Please enter date and amount of payment) Date: Amount: $
(Please enter gross amount of payment) Amount: $
(Please Explain)
Section B: Information Regarding the Employer/Entity Paying the Retirement Payment/Pension
Employer/Entity Name:
Address 1: Address 2: (Apt., Floor, Suite, etc.)
City: State: Zip Code:
Telephone Number: ( ) -
What was the last day the claimant worked for you? / /
What was/is the effective date of the retirement payment? / /
What is the gross monthly payment amount? $
Section C: Signature
Signature: Date: / /
Name (printed): Telephone Number: ( ) -
Title: Extension: