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The document is a form (UI-28) issued by the State of Illinois Department of Employment Security for employers to claim adjustments or refunds for erroneously paid contributions, interest, or penalties. It outlines the necessary information required from the employer, including details about overpayments and computations for each quarter of a specified year. The form must be completed accurately and submitted within three years of the erroneous payment, and it includes instructions for filing and potential audits.

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