Employment Unemployment Response

EMPLOYMENT UNEMPLOYMENT RESPONSE

Employer Name:    Employer Account No.:

Employer Contact Information

Claimant Personal Information

Claimant Name:

Phone:    Email:

Date of Birth:    SSN (last 4 digits):

Position Information

Department:    Manager/Supervisor:

Employment Start Date:    Separation/Last Day Worked:

Employment Status: Full-time Part-time Temporary/Seasonal

Employment History (Prior Employers)

Previous Employer 1

Title:    Dates Employed:

Previous Employer 2

Title:    Dates Employed:

Education

Graduation Date:

References (Professional)

Reason for Separation and Narrative

Separation Type: Voluntary Resignation Termination for Cause Layoff / Reduction in Force Medical Leave Other

Wages, Benefits and Final Pay

Last Pay Date:    Gross Wages Paid in Claim Period:

Vacation/PTO Paid on Separation:    Severance Paid:

Payroll ledger / pay stubs    Attendance / time records    Written warnings / disciplinary records    Employee resignation letter    Separation notice / termination letter    Other (describe below)

Availability for Agency Contact and Hearing

Phone:    Email:

Will a company representative attend an administrative hearing? Yes No

Legal Statements, Certifications and Authorizations

By signing below, the undersigned certifies under penalty of law that the information and documents provided on this form and any attachments are true, accurate, and complete to the best of the signatory's knowledge. The signatory further affirms that they are authorized by the employer to provide this response and to release payroll, attendance, disciplinary, and other employment records to the unemployment insurance authority for the purposes of adjudicating the claimant's benefit eligibility.

The employer acknowledges the obligation to retain originals of payroll and personnel records for a period required by applicable law and agrees to furnish originals or certified copies upon request by the administrative agency. Making a materially false statement on this form may subject the signatory and the employer to civil and criminal penalties provided by law.

Authorization: The employer authorizes the release of records and information contained in this response to the adjudicating authority, hearing officers, or their designees for the limited purpose of resolving the unemployment claim.

Employer Certification

I certify that I have reviewed the attached documentation, that the facts stated herein are correct, and that I understand that intentional misrepresentation or omission of material facts may result in penalties. I further certify that the employer retains records supporting this response and will produce them if requested by the adjudicating agency.

At-Will & Equal Employment Statements

The information provided in this response is supplied without altering or waiving any employer policies. Nothing in this document modifies the employment relationship or creates any contractual rights. The employer affirms its commitment to equal employment opportunity in accordance with applicable law.

Sign Now