UI-40B (Rev. 6/15 )
IL 427-0402 Stock                            State of Illinois
No. 7876                             Department of Employment Security
                                     Revenue Division - 307 East Jackson St,3rd Floor 
                                      Springfield, Illinois 62701
                                      Fax number 217-785-1725 

                   SOCIAL SECURITY NUMBER CORRECTION AND NAME CHANGE NOTICE 

                                                                     Please complete this schedule promptly. 

                                                                       Return original to this Division, Attention: 

                                                                            WAGE RECORDS 

                                                                       Retain duplicate for your files. 

Enter your Illinois Unemployment Insurance Account Number, 
name and Address in the space above. 

IF ADDITIONAL SPACE IS NEEDED, CONTINUE ON A PLAIN PIECE OF PAPER, ENTER YOUR ACCOUNT NUMBER, NAME AND 
ADDRESS AT THE TOP, AND HEAD EACH COLUMN AS ON THIS SCHEDULE. 

   Worker’s Social  Worker’s Name                           QUARTER         TOTAL                       Worker’s Social 
   Security  Number (Type or Print)                         ENDING          Wages Paid                  Security Number 
   AS REPORTED                                                                                          AS CORRECTED 

Date                                                        Signed

                                                            Title

For information & phone numbers, please visit,  http://www.ides.illinois.gov/SitePages/ContactIDES.aspx. 
For this & other online forms, please visit, http://www.ides.illinois.gov/forms