Fillable Unemployment Insurance Claim Application (Illinois)

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Unemployment Insurance Claim Application (Illinois)

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The Unemployment Insurance Claim Application (Illinois) form is 5 pages long and contains:

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  • 35 check-boxes
  • 325 other fields

Country of origin: US
File type: PDF

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State of Illinois
Department of Employment Security
www.ides.illinois.gov
Unemployment Insurance Claim Application
You must answer all items / sections marked with an asterisk ( * ). (Please Print or Type)
*Are you on break from school, attending school or enrolled in a training program?
CLI001F
Page 1 of 5
SN 4227
Rev. 9/2018
*Are you receiving or have you applied for Worker’s Compensation?
*Did you receive or will you receive plant shutdown / vacation pay?
*Are you receiving or have you applied for a pension?
*Did you receive or will you receive Holiday Pay?
*Have you filed a claim in another state in the past 12 months?
*Are you receiving or have you applied for Railroad Unemployment?
*Have you refused any offers of work since your last day of work?
*What were your gross wages during
the week of your last day worked?
*Did you work for an employer who has been certified for Trade Readjustment Allowance, (TRA)?
*What was your last day worked? (mm/dd/yyyy)
*What is your usual occupation?
*Do you have a definite return to work date? *If yes, provide the date: (mm/dd/yyyy)
*Do you get work through a Union Local hiring hall? *If yes, are you a member in good standing?
Union Local/District #:
City:
(Office Use Only) Occupational Code:
Union Name:
$
If yes, ask for TRA Application.
If yes, in which state(s):
If yes, did you make contributions to your pension fund?
Identification: (Check one and provide information)
Yes No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Claimant Information
Screening
E-Mail Address:
*First Name: MI: *Last Name:
If yes, in which city and state: When did you file?
,
*Date of Birth: (mm/dd/yyyy) / /
Claimant ID: OR *SSN: / /
State:
Driver's License Driver's License Number:
State:
State ID
State ID Number:
Other (specify)
/ /
/ /
NoYes
NoYes
*Did you work outside the state of Illinois during the last 18 months?
NoYes
Program:
TRA EUC
EB
UCX
UCFE
Soc. Sec. Card
Filing Method:
In Person
Identity verified using:
Rev By: Entered By:
Additional Information:
(Office use only)
BYB:
DOC:
Key Identifiers (phone)
Driver's License
Other:
Phone
State ID Alien ID DD-214
UI CWC
Attachments:
Driver's License
Other:
Enter your full name as it appears on your Social Security card.
*Have you been self-employed or an independent contractor since your last day of work?
State:
EEO
Mailing Address
Border State
Wisconsin, Indiana, Kentucky, Missouri, and Iowa
Tax Information
Citizenship
General Information (Check one in each section unless otherwise indicated)
(If you do not live in a Border State, skip to Tax Information)
(Illinois residents only)
* Are you a citizen of the United States?
(If yes, skip to the General Information Area)
* Are you authorized to work in the United States?
*Country: (Check one) U.S. (Includes U.S. Territories) Canada Other
*P.O. Box? *If yes, provide the reason your mail is to be sent to a P.O. Box.Yes No
In Care of:
*Address:
*Address:
*Apt / Unit#:
*Apt / Unit#:
ID or SSN: Last Name:
Primary Telephone: ( Secondary Telephone: () )- -
*City: *State: *Zip Code: *County:+
* Have you performed work in Illinois at any time during the last 18 months while living in a border state?
NoYes
English
Russian
*Language:
(Preference)
Hindi
Spanish
Mandarin
NoYes
*Disability:
Prefer not to answerYes
No
*Gender:
Male
Female Prefer not to answer
*Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
* Do you plan on looking for work in IL?
NoYes
* I elect to have Federal Income Tax withheld from my gross Unemployment Insurance Benefit
payments in the amount of 10 %
* I elect to have Illinois State Income Tax withheld from my gross Unemployment Insurance Benefit
payments in the amount of 4.95%
NoYes
* Are you temporarily laid off for 10 weeks or less from an Illinois employer?
NoYes
NoYes
NoYes
Residential Address (A Residential Address must be provided if you are using a P.O. Box or are living at an address that is different than your
Mailing Address)
(If no, skip to Border State)
*Country: (Check one) U.S. (Includes U.S. Territories) Canada Other
In Care of:
*City: *State: *Zip Code: *County:+
* Do you have a residential address that is different than your mailing address?
NoYes
* Alien Registration Number: * Entrance Date
/ /
* Expiration Date: * Document Type:
/ /
CLI001F
Page 2 of 5
Office Use Only: Retire this address in favor of mailing record?
NoYes
Secondary verification required
Homeland Security Verification Number:
NoYes
No
Office Use Only: Initial Verification with Homeland Security
Homeland Security Information Validated Yes
NoYes
Polish
Vietnamese
Arabic
Bosnian/Serbian/Croatian
Italian
Korean
Portuguese
Tagalog
Sign Language
German
TTY
Other
Cantonese
If you selected No to both questions, skip to Payment Method).
Prefer not to answer
Debit Card
Bachelor’s Degree or Equivalent
3 yrs College, Tech. or Voc. School
Associates Degree
Education Beyond Bachelor’s
Master’s
Doctorate
MD-Doctor of Medicine
JD-Doctor of Law
Vocational/Technical Degree or Certificate
1
st
Yr College, Tech. or Voc. School
9
10
11
2
nd
Yr College, Tech. or Voc. School
*Education Provide the highest level of education by checking one:
3
2
1
*Race: (check all that apply)
White Black/African American
Native Hawaiian or Other Pacific Islander
American Indian or Alaskan Native
Asian
*Dependent Type: (check all that apply)
None
Spouse
NoYes
*Was your discharge Dishonorable?
Yes No
*Payment Method Information
(Check one)
Direct Deposit (Request an Authorization Form)
*Veteran Information Have you served on active duty on the U.S. Armed Forces for more than 180 days
NOT including training for the National Guard or Reserves, and were issued a DD214?
NoYes
*Branch of Service
*Start Date
/ /
*End Date
/ /
CLI001F
Page 3 of 5
ID or SSN: Last Name:
Dependent Under 18
Dependent 18 or older (and unable to work due to illness/disability)
NoYes
00 (no school grade completed)
4 5
6 7
8
12 (completed, did not graduate)
GED
H.S. Diploma
Do you believe that you are a Seasonal Farmworker/Migrant after reading the definitions?
Definitions:
Certain types of seasonal agricultural work may qualify workers for additional services.
Seasonal means temporary jobs which last less than one year, excluding job termination.
Note: Agricultural work is defined as having worked in the farming of cash grain crops, vegetable crops, or fruits and nuts.
The following may qualify as seasonal agricultural work: working in a nursery or green house; livestock farming; working in hatcheries; crop harvesting;
or crop preparation.
Grass mowing, tree trimming, and sod growing do not qualify as agricultural work.
Migrant food processing includes working in canneries or packing sheds. It does not include working in places like Frito-Lay, fruit stands, Quaker Oats,
or similar establishments. Work in any food processing plant must have been both seasonal AND migrant. (The worker was provided housing as he/she
was unable to commute to his/her permanent residence on a daily basis).
*Are you a spouse of a Veteran injured, disabled or killed in the line of duty?
*Are you the spouse or other family caregiver of a wounded, ill, or injured service member ?
NoYes
(If you selected Yes to either question, ask for a Supplemental Veterans Form.
(If you selected Yes, ask for a Supplemental Form. If No, skip to the next question).
Note: If you choose Direct Deposit, payment will be made by Debit Card until your Direct Deposit request is Authorized.
*Dependent Type: Child (Include natural children, stepchildren, legally adopted children and children of whom you have court ordered custody).
Do you have children under the age of eighteen OR an older child who was unable to work during the past 90 days due to an illness or disability?
(If no, skip to Dependent Type: Spouse)
If you have more than two dependent children under 18, request Dependent Listing Form.
*Dependent Child 18 or Older with Illness / Disability: (Provide the name, SSN, and birth date of your Dependent Child 18 or Older)
*What is the illness or disability?
Dependent Detail
(If you do not wish to claim dependents skip to Employment History)
NoYes
*Number of Dependent Children Under 18:
Children
(Provide the name, SSN and birth date starting with your youngest child)
*First Name *Last Name SSN *Date of BirthMI
*First Name *Last Name SSN *Date of BirthMI
If you have more dependent children 18 or older with illness or disability, request Dependent Listing Form.
1a) *Do you and the children’s other parent live in the same household? (If no, skip to question 2)
1b) *Did you and your spouse together provide more than 50% of the support of the children during the past 90 days and did you
provide at least 25% of that support?
NoYes
NoYes
2) *If you and the children’s other parent do not live in the same household, did you furnish more than 50% of the support for
the children during the past 90 days?
NoYes
3) *Within the past 12 months, up to today, has anyone else claimed any of your children on an Illinois Unemployment
Insurance Claim?
If Yes, what is the name and SSN of the person claiming the dependent child/children?
NoYes
NoYes
*Within the past 18 months did your spouse work in Illinois?
*For the 90 consecutive days before this claim, did you furnish more than 50% of the cost of support for your lawful spouse?
NoYes
Spouse
*Name: *SSN:
- -
/ /
-
-
*Dependent Type: Spouse (or civil union partner)
*SSN:
*First Name: MI: *Last Name:
Date of Birth:
CLI001F
Page 4 of 5
ID or SSN:
Last Name:
Claimant Certification - Please Read Carefully
I hereby file a claim for unemployment insurance benefits. I certify that the information for my benefit claim, including the status of my
dependents, is true and correct to the best of my knowledge and belief. I am aware that the law prescribes penalties of fine and imprisonment
for making false statements to obtain benefits, including dependent allowance. I understand that the information submitted by me may be
verified through computer matching programs and will be used by other Federal, State, or Local Agencies and that information submitted by me
to these agencies will be used by IDES in determining my eligibility and amount of unemployment benefits. I also understand that, pursuant to
Section 1900 of the Unemployment Insurance Act, any information that I provide to the Department of Employment Security in connection with
the claim may be shared with my former employers or their representatives.
I understand that, unless I am exempt, registration for work with the Illinois Employment Service is a requirement to be eligible for
Unemployment Insurance Benefits under Section 500A of the Illinois Unemployment Insurance Act; unemployment insurance benefits will not be
paid until I complete my registration; and registration can be completed by visiting www.IllinoisJobLink.com.
*CLAIMANT SIGNATURE: *DATE:
Employment History List where you have worked during the past 18 months. (Start with your most recent job.)
If you worked for a Temporary Agency, provide the name, address, and phone # of the Agency.
If you need to list more employers, request the Work History Form.
Employer Name:
*Employer Name:
*Address:
*Why are you no longer working for this employer? (check one)
If you worked for a Temporary Agency provide the name of the employer you worked for or were assigned to.
If you have other employers in the past 18 months, list below. If none, skip to Claimant Certication.
*What was your most recent job title:
*City: *State: *Zip
*Company Phone #: ( )
-
*For this period of employment, what date did you start?
*Last date worked:
/ /
/ /
*In what state(s) was your work performed?
/ / /
Total # of days worked:
Quit
Strike / Lockout / Labor Dispute (Ask for LD Questionnaire)
Laid-Off (Lack of Work)
Still Working (Part Time)
Discharged (Fired)
Military Discharge
*Employer Name:
Employer Name:
*Address:
*Why are you no longer working for this employer? (check one)
If you worked for a Temporary Agency provide the name of the employer you worked for or were assigned to.
*City: *State: *Zip
*Company Phone #: ( )
-
*In what state(s) was your work performed?
/ / /
Total # of days worked:
Laid-Off (Lack of Work)
Quit
Strike / Lockout / Labor Dispute (Ask for LD Questionnaire)
Still Working (Part Time)
Discharged (Fired)
Military Discharge
/ /
CLI001F
Page 5 of 5
(Ofce Use Only) UI Acct#:
(Ofce Use Only) UI Acct#:
LEU
LEU
LAG
LAG
BCE
BCE
*How many weeks OWBA:
*How many weeks OWBA:
*For this period of employment, what date did you start?
*Last date worked:
/ /
/ /
ID or SSN:
Last Name:
Other Last Name worked under _________________________________
Typically, how many days in a week did you work for this employer ? _______
Typically, how many days in a week did you work for this employer ? _______
Other Last Name worked under ________________________
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Unemployment Insurance Claim Application (Illinois)

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Completed 20 May 2021

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