5/14/2025 4:26:01 PM - [Info] GetOcrOutput - OCR output for page 3: This notice is being sent to you because you are the Chargeable Employer for whom the claimant worked for 30 days (not necessarily consecutively) from the beginning of the claimant's Base Period to the "Date of Claim." You will be charged for any benefits paid to him/her. There is no connection between the amount that you paid the claimant and the amount you will be charged The claimant's benefits are based on his/her wages during the first four of the last five completed calendar quarters (Base Period) prior to the claimant's Benefit Year Begin." You will be charged for the benefits paid even if the wages you paid the claimant are not used in calculating his/her benefits. lfthe claimant worked for you for less than 30 days, you can be charged because you were the single employer that paid the claimant enough wages to requalify the claimant after a disqualifying separation from a previous employer. Rules on charging can be found at 56 iII. Adm. Code 2765.325 et seq. [See www.ides. illinois.gov under rules.] FOR INFORMATION REGARDING YOUR RIGHTS UNDER ILL NOIS' UNEMPLOYMENT INSURANCE ACT, INCLUDING INFORMATION ON HOW TO OBTAIN FREE LEGAL SERVICES, AND THE EXACT LANGUAGE OF THE ACT AND IDES RULES, PLEASE VISIT THE AGENCY'S WEBSITE AT www.ides.illinois.gov/UlRights. If you wish to protest the claimant's right to benefits because he/she received vacation pay in connection with his/her separation. in your response, you must indicate the period covered by the vacation pay and the amount of the pay. Your protest must be filed by the "Reply Due Date" within 10 or days of the date that the vacation pay is paid or becomes payable. if the payment was made for an announced period of vacation or inventory shutdown, it is not necessary to make this designation Appeal Rights If your protest is not postmarked, faxed, or successfully submitted via SIDES by the "Reply Due Date", you will not have the right to appeal a determination that is not in your favor. Hovever, you can protest at any time that the claimant was not able, available or actively seeking work, giving details. You can also protest anytime that the claimant was not unemployed or thet the claimant is receiving a retirement pension. in those cases, you would have the right to appeal a determination for periods after the date that you fled your protest. Even if your protest is late, we will still consider any information that you provide. However, you will not be able to appeal our determination. Keep your business information up lo date. To make a change of address for forms such as Notice of Claim (ADJ030F) and Etatement of Benefit Charges (BEN 118), visit www.mytax.illinois.gov and make required changes or submit a Notice of Change {UI-50A) available at www.ides.illinois.gov. NOTE: All agents must have power of attorney on file to request a change of address. Please complete, sign and return this form by 02/13/2025, address listed to the Agency at the above, is not NOTE: mail If you choose fax protest, as to your it necessary to well. IF YOU ARE RESPONDING TO THIS NOTICE, PLEASE PLACE ADDITIONAL DOCUMENTS BEHIND ANY BAR-CODED PAGE. Please select one of the following and complete all other related information: CÃ­did not employ the claimant for 30 days Start Date End Date: Total Number of Days Worked: 3 Leased employee (Please identify leasing Agency Name and Address) Agency Name Address 1 City Address 2 (Apt., Floor, Suite, etc.) State Zip Code 7 Claimant never worked for me I certify that the information contained herein is true and correct. Name (printed): Title: Date: ri Claimant is not unemployed *NOTE: Claimant may still be eligible if working part-time Signature: Contact Name (if different): Telephone Number: J30F Page 3 of 3 ADJ030F BIS 32

