EXTREMELY IMPORTANT NOTE REGARDING THE ENTRY OF
This form requires the entry of confidential information. Therefore, it is
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Before submitting this form please verify that all required information is
fully completed and that all information matches what you would have
provided to the Department of Labor when you originally filed your claim.
You indicated that you would like to CHANGE
your income tax withholding status. To facilitate this
request, please answer the following questions and
a representative will work on your request, it
may take up to three business days.
* - Denotes required field
I certify that I
am the claimant indicated below. I understand that the law provides
penalties for making false statements or any misrepresentation to
obtain unemployment benefits.
Mother's Maiden Name (for
Date of Birth (for
(to contact you only for
tax withholding status you would like:
Yes - Withhold
No - Do NOT Withhold