Form Adj009Fc PDF Details

Navigating the complexities of unemployment documentation can sometimes feel overwhelming, yet understanding the Adj009Fc form is a critical step for individuals in Illinois facing unemployment. Sponsored by the State of Illinois Department of Employment Security, this form serves as a Wage Questionnaire for claimants, providing a structured way to report various types of wages and payments which could affect their unemployment benefits. Distinct sections of the form inquire about services performed, any wages or payments received post-employment, including severance pay, payment in lieu of notice of separation or layoff, back pay awards, among others. The form meticulously guides the claimant through documenting employer information, service details, and the specifics of any payments received under different scenarios. Completing and returning this form accurately is essential; failure to do so could lead to a determination based on available information which might not reflect the claimant's actual situation. Furthermore, the form is available in multiple languages, acknowledging the diverse population it serves, with a clear message for those who might need an interpreter. Each section is designed to ensure that all necessary information is captured, allowing the Department of Employment Security to make an accurate assessment of the claimant’s unemployment benefits eligibility.

QuestionAnswer
Form NameForm Adj009Fc
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespngase, unemployed individual wage questionnaire, Illinois, usted

Form Preview Example

State of Illinois

Department of Employment Security

www.ides.illinois.gov

Unemployed Individual – Wage Questionnaire - Claimant

Claimant Information:

Last Name:

 

First Name:

 

MI:

ID or SSN:

(Este es un documento importante. Si usted necesita un intérprete, póngase en contacto con su oficina local.)

Under Section 239 of the Illinois Unemployment Insurance Act, an individual shall be deemed unemployed in any week with respect to which no wages are payable to him and during which he performs no services or in any week of less than full-time work if the wages payable to him with respect to such week are less than his weekly benefit amount.

Please complete, sign and return this questionnaire to your Illinois Department of Employment Security Local Office as instructed. Failure to respond will result in a determination based on the available information. If you need additional space, please use the other side of this document, if appropriate, or attach a separate sheet of paper.

Employment Information

Have you or will you perform any services and/or receive wages or

 

 

payments from your employer any time after

?

Yes

No

If No, proceed to Section G. Please sign and return this questionnaire, no further information is necessary.

If Yes, what services or payments did or will you receive?

(Check all that apply and complete corresponding section)

 

A. Wages for services performed after

 

 

 

 

 

 

 

 

B. Perform(ed) services after

 

 

for which no payment will be received

 

 

 

 

 

C. Severance pay

 

 

 

 

 

 

 

D. Payment in lieu of notice of separation or layoff

E. A back pay award (payment resulting from grievance)

F. Other: (Explain)

 

Provide information about the employer who made this payment or received services after

.

 

 

 

 

Employer Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address 1:

 

 

 

 

 

 

 

 

 

 

 

Address 2: (Apt., Floor, Suite, etc.)

 

 

 

 

 

 

City:

 

 

 

 

 

 

State:

 

 

Zip Code:

 

 

 

 

 

 

 

Employer Telephone Number: (

)

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section A & B: Services Performed Details

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If A or B were checked, answer the following regarding wages/payments received and/or services performed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates worked after

 

 

 

 

 

 

 

Hours worked per day

 

 

Gross earnings per day

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

Hours

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

Hours

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

Hours

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

Hours

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

Hours

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Proceed to Section G

Section C: Severance Payment Details

If C was checked, answer the following questions regarding severance pay.

Was payment based on length of service?

 

What was payment amount?

$

Yes

No

Proceed to Section G

ADJ009FC

Page 1 of 2

QU02

Rev. (09/2011)

Section D: Payment in Lieu of Notice Details

If D was checked, answer the following questions regarding payment in lieu of notice of separation or layoff.

Is there an employment agreement, a statutory requirement or a uniformly applied company policy which

 

 

 

 

 

 

 

 

requires the employing unit to give the employee a definite period of notice before a layoff or separation?

 

 

 

Yes

No

If Yes, how much notice is required?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you receive the required notice?

 

Yes

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, date notice was given.

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If no notice was given, were you paid a sum equal to your regular wages for the required period of notice?

 

 

 

Yes

No

What was the gross amount of payment received?

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For what period was the payment allocated?

 

From:

 

 

/

 

 

 

/

 

 

 

 

 

 

 

To:

 

/

 

 

 

/

 

 

 

 

 

What date was the payment made?

 

 

 

 

 

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What was your average gross weekly wage?

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Proceed to Section G

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section E: Backpay Award Details.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If E. was checked, answer the following questions regarding back pay award.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What was the gross amount of payment received for backpay?

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For what period was the payment allocated?

 

 

 

From:

 

 

/

 

/

 

 

 

 

 

 

To:

 

/

 

 

/

 

 

 

 

 

 

What date was the payment made?

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What was your average gross weekly wage?

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was any part of the payment not related to lost wages?

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was the amount of back pay related to the amount of wages lost?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, in what way?

How was the amount of the award determined?

Proceed to Section G

Section F: Other

If F. was checked, what other type of payment have or will you receive from your employer? (Details such as type of payment, amount, dates, etc. must be documented).

Proceed to Section G

Section G: Signature

Signature(s):

 

 

Date:

/

/

 

 

 

 

 

 

 

 

 

 

 

 

Name (printed):

 

 

Telephone Number: (

)

-

 

 

 

 

 

 

 

 

 

 

 

 

ADJ009FC

Page 2 of 2

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Part number 1 in filling out Claimant

2. The next part would be to complete these fields: E A back pay award payment, F Other Explain Provide, Employer Name, Address Address Apt Floor Suite, City State Zip Code, Employer Telephone Number, Section A B Services Performed, If A or B were checked answer the, Dates worked after, Hours worked per day, Gross earnings per day, Hours, Hours, Hours, and Hours.

Claimant conclusion process detailed (portion 2)

3. The following part is focused on If C was checked answer the, Was payment based on length of, What was payment amount Proceed, and ADJFC Page of QU Rev - fill out all these fields.

Ways to fill in Claimant portion 3

4. Filling in Section D Payment in Lieu of, If D was checked answer the, If Yes how much notice is required, Did you receive the required, If Yes date notice was given, If no notice was given were you, What was the gross amount of, For what period was the payment, What date was the payment made, What was your average gross weekly, Proceed to Section G, Section E Backpay Award Details, If E was checked answer the, What was the gross amount of, and For what period was the payment is vital in the fourth step - make certain that you take the time and take a close look at every single blank!

Claimant writing process described (stage 4)

5. To conclude your form, the final part features a couple of additional blanks. Completing For what period was the payment, What was your average gross weekly, Was any part of the payment not, If Yes please explain Was the, If Yes in what way, How was the amount of the award, Section F Other, If F was checked what other type, Details such as type of payment, Section G Signature, Signatures Date, and Name printed Telephone Number will conclude everything and you can be done in no time at all!

For what period was the payment, If F was checked what other type, and If Yes please explain Was the of Claimant

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