unemployment ONLINE aSSISTANCE CENTER
Returned to Work
 
EXTREMELY IMPORTANT NOTE REGARDING THE ENTRY OF CONFIDENTIAL INFORMATION: This form requires the entry of confidential information. Therefore, it is extremely important for you to close down your browser completely after submitting this form. This will prevent others from accessing the information you have entered. To close down your browser, click the "x" in the top right-hand corner of the browser window.
 
IMPORTANT NOTE: 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 have indicated that you have returned to work. 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.

* I AGREE
 


* Full Name:   

* SSN      (###-##-####)

* Mother's Maiden Name (for verification purposes):   
 

* Date of Birth (for verification purposes):       (MM/DD/YYYY)

Email Address: (to contact you only for confirmation)
 

Contact Phone:      
 

RETURN TO WORK INFORMATION

* Returned to Work: Full-Time  Part-Time

* Return to Work Date:                  (MM/DD/YYYY)

* Employer Name:   

* Employer Address (or Town/State):  

* Please provide gross earnings and hours for the return to work week:

Gross earnings - $   Hours worked -

NOTES

  1. If you are returning to work part time please click here to check the “Filing for Benefits While Working Part-Time” section to see if you may be eligible for partial benefits.
     

  2. If your return to work date falls in the middle of a full work week (Sunday through Saturday) please be sure to report the total number of hours worked and gross wages when you file your weekly claim, as you may be eligible for a partial benefit.

  

VERY IMPORTANT NOTE: If the form instructs you to make changes AFTER pressing the "Submit" button, return to the form by pressing the "Back" button on your computer. This will retain the information you've already entered. If you press the "Return to the Form" link at the bottom of the page, you will lose all of the information you've previously entered.