Form BPC039L "Interstate Intercept Claimant Agreement Statement" - Illinois

What Is Form BPC039L?

This is a legal form that was released by the Illinois Department of Employment Security - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2010;
  • The latest edition provided by the Illinois Department of Employment Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form BPC039L by clicking the link below or browse more documents and templates provided by the Illinois Department of Employment Security.

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Download Form BPC039L "Interstate Intercept Claimant Agreement Statement" - Illinois

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State of Illinois
Department of Employment Security
Phone:
TTY:
Fax:
www.ides.state.il.us
Date Mailed:
ID/SSN:
Interstate Intercept Claimant Agreement Statement
Print
Este es un documento importante. Si usted necesita un intérprete, póngase en contacto con su oficina local.)
I understand that the Unemployment Insurance Claim I filed against the State of Illinois was filed in error because I was eligible
to file against
.
As a result, I understand that Unemployment Insurance benefits received by me from Illinois were overpaid benefits within the
meaning of the Illinois Unemployment Insurance Act.
I thereby, agree to have benefits sufficient to recover the amount of $
overpaid by Illinois, withheld from the
Unemployment Insurance claim which I filed (or will be filed) against
and forwarded
to Illinois. My debt to Illinois will be absolved to the extent by which my overpayment is reduced as a result of this action.
(Claimant’s Signature)
(Date)
BPC039L
Page 1 of 1
Rev. (05/2010)
State of Illinois
Department of Employment Security
Phone:
TTY:
Fax:
www.ides.state.il.us
Date Mailed:
ID/SSN:
Interstate Intercept Claimant Agreement Statement
Print
Este es un documento importante. Si usted necesita un intérprete, póngase en contacto con su oficina local.)
I understand that the Unemployment Insurance Claim I filed against the State of Illinois was filed in error because I was eligible
to file against
.
As a result, I understand that Unemployment Insurance benefits received by me from Illinois were overpaid benefits within the
meaning of the Illinois Unemployment Insurance Act.
I thereby, agree to have benefits sufficient to recover the amount of $
overpaid by Illinois, withheld from the
Unemployment Insurance claim which I filed (or will be filed) against
and forwarded
to Illinois. My debt to Illinois will be absolved to the extent by which my overpayment is reduced as a result of this action.
(Claimant’s Signature)
(Date)
BPC039L
Page 1 of 1
Rev. (05/2010)