Unemployment Verification Form

UNEMPLOYMENT VERIFICATION FORM

Claimant Personal Information

Full Legal Name:

Phone:    Email:

Position Information (Employer to Complete)

Job Title:    Department:

Reporting Manager:

Employment Start Date:    Last Day Worked:

Base Pay Rate (per hour or salary):    Typical Hours Per Week:

Reason for Separation (Employer to Check All That Apply)

  Layoff / Lack of Work      Voluntary Resignation      Termination for Cause

  Reduction in Force      Medical/Disability      Other (explain below)

Compensation and Benefits at Separation

Final Pay Date:    Final Gross Pay Amount:

Severance Paid:   Yes      No    If Yes, Amount:

Accrued PTO / Vacation Paid:   Yes      No    If Yes, Amount:

Eligible for Rehire:   Yes      No

Employer Verification Contact

Title:    Phone:

Employment History (Claimant)

Previous Employer 1

Title:    Dates Employed:

Previous Employer 2

Title:    Dates Employed:

Education & References

Institution:    Graduation Date:

Professional References (3)

Legal Disclosures

At-Will Employment Statement: Nothing in this form alters any previously agreed employment relationship. Unless otherwise stated in a separate written agreement signed by an authorized officer of the employer, employment is at-will and may be terminated by either party at any time, with or without cause or notice.

Equal Employment Opportunity: The employer certifies that it does not discriminate in employment on the basis of race, color, religion, sex, national origin, age, disability, or any other classification protected by applicable law. This verification is made in accordance with the employer's non-discrimination policies.

Claimant Certification & Authorization

I certify under penalty of perjury that the information I have provided on this form is true and complete to the best of my knowledge. I authorize my current and former employers to release employment dates, earnings information, separation reason, and other employment-related records necessary for the adjudication of my claim for unemployment benefits.

I understand that false statements or misrepresentations made for the purpose of obtaining unemployment benefits may subject me to civil or criminal penalties, and may require repayment of benefits received.

I authorize the release of my employment records described above and consent to verification contacts by the employer or its designated agents. This authorization remains effective for the duration necessary to process and adjudicate my unemployment claim.

Additional Employer Comments (Optional)

Attachments

Indicate documents attached to support this verification (pay stubs, separation notice, final paycheck stub, severance agreement).

  Pay stubs      Separation notice      Final pay stub      Severance agreement

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