First, enter the name that appears in your employee records. If the employee’s name is different in your records than it is on their Social Security card, you should report both names. Then, enter the Social Security Number of the employee. Make sure it’s verified as correct.
First, enter the name that appears in your employee records. If the employee’s name is different in your records than it is on their Social Security card, you should report both names. Then, enter the Social Security Number of the employee. Make sure it’s verified as correct.
Enter the dates that the employee most recently worked.
Enter the dates that the employee most recently worked.
If the employee is being separated because of a lack of work, you should put a checkmark in the indicated box. If the employee’s separation is for any other reason, use the provided space to write complete details about the separation. If it’s necessary, you should add another sheet of paper.
If the employee is being separated because of a lack of work, you should put a checkmark in the indicated box. If the employee’s separation is for any other reason, use the provided space to write complete details about the separation. If it’s necessary, you should add another sheet of paper.
If the company made any kind of payment to the employee, such as separation pay, you should indicate what type of payment was made. Also indicate the time period the payment was made for beyond the employee’s last day of work. You’ll need to provide the date that the payment either was or will be issued. Make sure you don’t include earned wages or vacation pay.
If the company made any kind of payment to the employee, such as separation pay, you should indicate what type of payment was made. Also indicate the time period the payment was made for beyond the employee’s last day of work. You’ll need to provide the date that the payment either was or will be issued. Make sure you don’t include earned wages or vacation pay.
Check “Yes” or “No” regarding whether the employee’s earnings exceeded $3,500. If the answer is no, you should write the wage amount earned while the employee worked for you. Also indicate the average weekly wages when the separation occurred, not including overtime.
Check “Yes” or “No” regarding whether the employee’s earnings exceeded $3,500. If the answer is no, you should write the wage amount earned while the employee worked for you. Also indicate the average weekly wages when the separation occurred, not including overtime.
Fill out the full name of the employer.
Fill out the full name of the employer.
Give the employer’s full mailing address regarding the place where they will receive communications about potential claims.
Give the employer’s full mailing address regarding the place where they will receive communications about potential claims.
Check the Quarterly Tax and Wage Report for your company to find your state DOL account number for unemployment insurance.
Check the Quarterly Tax and Wage Report for your company to find your state DOL account number for unemployment insurance.
Sign and date the document. The date should be the date the document is given to the worker.