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UIA 1538 (Rev. 11-11) Authorized by MCL 421.1, et seq. State of Michigan Department of Licensing and Regulatory Affairs Unemployment Insurance Agency What You Need To File An Unemployment Claim If you have become unemployed or have had your hours of work reduced, you may ile a claim for unemployment beneits. You may ile your claim by telephone toll-free at 1-866-500-0017 (TTY customers use 1-866-366-0004), or ile via the Internet at http://www.michigan.gov/uia under the heading, “Filing Unemployment Claims Online.” Completing the information on this sheet irst will save you time when you ile your claim for unemployment beneits. DO NOT SEND THIS FORM TO THE UNEMPLOYMENT INSURANCE AGENCY (UIA). KEEP IT FOR YOUR RECORDS. PERSONAL INFORMATION Social Security Number: Driver license number or state ID number: Mailing address (where you want information about your unemployment claim sent): Telephone number (If you do not have a phone, give a number where a message can be left in case UIA staff need to contact you): Method of Payment: You will be asked to choose if you want your beneit payments issued by direct deposit to your bank or credit union account or by debit card: _______ Direct Deposit ______ Debit Card If you are not a citizen or national of the United States, give your Alien Registration Number and the expiration date shown on your alien ID or documents: You will need the names and payroll addresses for all the employers you have worked for in the 18 months prior to iling your claim. You will also need the date you started work and ended work with each of these employers. If any of the employers provided you with Form UIA 1711, Unemployment Compensation Notice to Employee, have the form(s) available. You may be asked to provide the UIA with some of the information contained on the form. It would also be helpful to have available any W-2 forms you have received from employers you have worked for in the past 18 months, as the form contains the employer’s Federal Employer Identiication Number (FEIN). EMPLOYMENT INFORMATION Your Most Recent Employer #1 (Separating Employer): Street Address (use the payroll address if known): City, State and Zip Code Dates of employment and earnings (report your gross earnings for your most recent period of continuous employment with this employer): Beginning Date: _______________ Ending Date: _______________ Earnings: _______________ LARA is an equal opportunity employer/program. UIA 1538 (Rev. 11-11) Reverse Side List all other employers you have worked for in the past 18 months giving the payroll address if known (use additional paper if necessary): EMPLOYER #2 Name: Payroll Address: City, State and Zip Code: Dates of Employment: Beginning Date: _______________ Ending Date: _______________ EMPLOYER #3 Name: Payroll Address: City, State and Zip Code: Dates of Employment: Beginning Date: _______________ Ending Date: _______________ DATES When entering dates, either on the web or the telephone, you must enter two digits for the month, two digits for the day, and four digits for the year. Example: October 3, 2011 should be entered as 10/03/2011 on the web or 10032011 on the phone. WAGES Your beneit entitlement will be based on gross wages paid in the irst four of the last ive completed calendar quarters immediately preceding the Sunday of the week in which you ile your claim. If there are insuficient wages in those quarters, the wages in the last four completed quarters will be used. For example, if you iled for beneits on Wednesday, November 12, 2011, the wages paid during the calendar quarters below would be used to compute your beneit entitlement. July 1, 2011 through September 30, 2011 April 1, 2011 through June 30, 2011 January 1, 2011 through March 31, 2011 October 1, 2010 through December 31, 2010 July 1, 2010 through September 30, 2010 You may be asked to provide quarterly wages if they were not reported by your employer(s). You should have the information available before iling your claim. INTEREST: Interest accrues at the rate of 1% per month (computed on a daily basis) as provided in Act No. 14 of the Public Acts of 2011 and Section 15(a) of the MES Act. If you have any questions about this form, call the UIA at 1-866-500-0017 (TTY customers use 1-866-366-0004).