1. Were you able to work, available
for work, and actively
seeking full-time employment?
1a. Have you previously reported that
you are only available
for part-time work because of a physical or
2. Did you refuse an offer
of work or rehire, quit a job or get discharged from a job?
3. Did you receive your
first payment from a pension other than Social Security, or was
there a change in the amount previously reported?
you start school, college, or training which you have not already
reported to the Labor Department?
5. Did you receive
vacation pay, severance pay or workers compensation benefits, not
previously reported to the Labor Department?
6. Did you work for an
employer or in self-employment?
7. Have you changed your mailing
address since you last filed a claim?
If yes, click here to
complete the Address Change Form.
I certify that I have answered the
truthfully and understand that giving false
information or answering questions for anyone other than myself
constitutes FRAUD and is punishable by law.
You must provide an explanation for why you are filling out this
form. If you are an on call employee please give us more information
you answered No to question 1 or Yes to questions 2-7 please provide
an additional explanation below(ex: reason you are not available,
employer you refused work from or quit, details of pension,
schooling, or severance etc.) :