Unemployment Claim Form

UNEMPLOYMENT CLAIM FORM

Personal Information

Position and Last Employment

Last day physically worked:    Date separated (official):

Separation Details (Select all that apply)

Reason for separation: Layoff/Position eliminated   Terminated for cause   Voluntary quit   Reduction in hours   Medical/Disability   Other (explain below)

Employment History (Most Recent 2 Employers)

Benefits, Other Income, and Claim Status

Are you currently receiving or scheduled to receive severance pay?   Yes    No

Are you receiving or eligible for pension or disability benefits?   Yes    No

Are you currently performing any paid work (including part-time or gig)?   Yes    No

Education

References (Professional)

Legal Disclosures and Authorization

At-Will Employment: Submission of this claim does not alter any prior employment relationship. Where applicable, the claimant acknowledges that previous employment may have been at-will and that this form is provided solely for the purpose of establishing eligibility for unemployment compensation.

Equal Opportunity: The claimant affirms they have not been discriminated against on the basis of protected characteristics in the events leading to this claim. The claimant may be asked to provide additional documentation to support nondiscrimination assertions.

Authorization to Verify: I authorize any past or present employer, educational institution, government agency, insurance carrier, or benefit plan administrator to release information concerning earnings, employment dates, reason for separation, and benefit payments to the agency processing this claim. This authorization remains effective for the duration of the claim and any related appeals.

False Statements and Penalties: I understand that knowingly making a false statement or failing to disclose material information in connection with an unemployment claim is a violation subject to penalties under applicable law, including denial of benefits, repayment obligations, fines, and other criminal or civil penalties.

I consent to background checks and wage verification as necessary to process this claim.

Applicant Certification

I certify under penalty of perjury that the information contained in this form is true, complete, and correct to the best of my knowledge. I will promptly notify the agency processing this claim of any change in my availability for work, income, address, or other circumstances that may affect my eligibility. I understand that submission of inaccurate or incomplete information may result in denial or forfeiture of benefits and may subject me to penalties provided by law.

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