VACATION SHUTDOWN STATE OF CONNECTICUT

VACATION SHUTDOWN NEW CLAIM

FOR UNEMPLOYMENT COMPENSATION BENEFITS

Form UC-62V (Rev 9/14)

STATE OF CONNECTICUT

DEPARTMENT OF LABOR EMPLOYMENT SECURITY DIVISION

IMPORTANTE: TENGA ESTO TRADUCIDO INMEDIATAMENTE

Print your Social Security No. here. (Be sure to copy from your Soc. Sec. Card)

_

_

(One Number Per Block)

NAME (Please Print) First

(Middle Init.)

(Last)

I

DATE OF BIRTH

Mo

Day

Year

SEX M F

CLAIMANT INFORMATION MAILING ADDRESS (No. & Street) or (P.O. Box Number)

CITY (DO NOT ABBREVIATE)

STATE ZIP

Town you live in if different from mailing address

MARITAL STATUS Sing. Marr. Wid. Sep. Div.

1.

2.

3.

4.

5.

TELEPHONE NO.

Complete form by Friday of the first week which you claim benefits and return to:

Claims Exam Unit Dept of Labor 200 Folly Brook Blvd Wethersfield, CT 06109

Are you a U.S. Citizen? If No, I certify that I am in satisfactory alien status. Attach copy of front and back of card and write alien number here.

Are you able and available for full-time work? Did you start receiving a pension or other retirement benefits within the last 24 months? If yes, name of employer:

Are you attending school or training?

Are you a construction worker? Have you worked (either full or part-time) for any other employer in the last 6 months? (if YES, complete Section VIII on back)

YES NO In the last 24 months have you:

Worked in another state? If yes, what state(s)? Worked for a federal agency? If Yes, complete section VIII Served in the Armed Forces? If Yes, complete section VIII

Worked for an educational institution? Been a corporate officer, self-employed, owner of a business? Worked under another name? (If "Yes," print name here.)

YES NO

TAX WITHHOLDING I ELECT TO HAVE FEDERAL (10%) AND CT STATE (3%) INCOME TAX WITHHELD FROM MY UNEMPLOYMENT BENEFITS

YES

NO

AUTHORIZATION

I hereby serve notice of intent to apply for unemployment benefits. I request and agree to accept the establishment of a Benefit Year, if none is in effect. I authorize the release to the Department of Labor of such wage and other information that may be required to determine my eligibility for Unemployment Compensation Benefits. I certify that the information provided on both the front and back of this form is true and correct. I understand that a false statement or failure to disclose material facts to obtain benefits is a violation of the law.

SIGNED (Claimant)

DATE

See Disclosure Information on reverse of

form

COMPLETE THE OTHER SIDE IF YOU WISH TO FILE FOR DEPENDENCY ALLOWANCE OR IF YOU WORKED FOR A FEDERAL OR MILITARY EMPLOYER

II.

Effective Date Mo. Day Year

Tax With.

Date Reported Mo. Day Year

S.A.C.

No. Dep.

Spouse

RNO

Occ. Code

YES

NO

Allow.

Yes No

FOR

Branch of Military Service

UCX Employer Number

Mass Layoff UC-893 ES-931 ES-973 1B-4

OFFICE

FFR Issue No. 01. Vol. Leaving 02. Vol. Retirement

PRIM.

1. X

2.

3.

4.

5.

USE ONLY

03. Student Quit

04. Willful misconduct or felonious

conduct

05. Refusal of Rehire

06. Refusal of Work 07. Able Available

SEC.

Name Street

PENSIONING EMPLOYER

PAYMENT ALLOC: Type Code: 1. Sev. 2. Vac. 3. Hol. 4. Other

Type Code

AMOUNTS

Stat

Non stat

Allocated to Week Ending

Mo.

Day Year

08. Reasonable Eff.

09. Sec. Ben. Year

(5 X WBR or $300)

City

10. Disq. Income

11. Deduct. Income (pot. earn, etc.) 12. Student Avail.

State

13. Invalid Filing

PROGRAM

UV

15. Labor Dispute SEC. EMP FFR

16. FSC. TRA

Yes

No

20. Monetary

(inc. dep. allow)

21. 10 x WBR (quit)

22. 10 x WBR (discharge)

23. 40 x WBR (vol. Ret.) 24. 5 x WBR or $300 (2nd ben. yr.)

DATE UC-952 MAILED

Reg. #

Mo

Day

Year

C.S.R.

J.C. Number

0

25. Sec. 31-227(d)(e)(f)

REMARKS

31. 6 x WBR (Refusal of Rehire/Work)

32. 4 x 4 (Requal wage FSC, TRA)

1. CT. REGISTRATION NO.

3. COMPANY NAME, STREET, TOWN, SATE AND ZIP CODE

4. EMPLOYEE'S NAME

III.

ADDRESS TO WHICH NOTICE OF FACT FINDING

HEARING WILL BE SENT.

EMPLOYER

2. NCCI CODE

INFORMATION

5. EMPLOYEE'S SOCIAL SECURITY NO.

(TO BE COMPLETED BY EMPLOYER)

Use this form if there is a DEFINITE return to work date (#9) that is 6 weeks or less from the date last worked (#8). Also, there should be no other issues involved. Otherwise, please use the Separation Packet Form UC-62T.

7. LENGTH OF MOST RECENT PERIOD OF EMPLOYMENT

YRS

MOS

DAYS

8. DATE LAST WORKED

11. REASON FOR UNEMPLOYMENT LACK OF WORK ? TEMPORARY COMPANY SHUTDOWN

6. WAGES FOR LAST WEEK OF WORK FROM SUNDAY TO DATE LAST WORKED (If less than full week)

NO. OF HOURS

WAGES

9. RETURN TO WORK DATE 10. Will any payment be made or has any payment been

No

made which is not wages for work actually performed

during period of unemployment?

Yes

12. TYPE OF PAYMENT (If yes to # 10) 13. LAST DATE COVERED BY PAYMENT

1. Severance

2. Vacation

3. Holiday

4. Other

Type

No. of Hours/Days Covered AMOUNT

DATES COVERED

14. I certify that the information in this notice is true and correct

SIGNATURE AND TITLE OF OFFICIAL

( ) TELEPHONE NUMBER

DATE

Office Use Claimant Stmt.

Yes

IV

DISCLOSURE INFORMATION

Information concerning an individual's unemployment compensation claim may be disclosed, under certain circumstances, to other governmental agencies pursuant to Title XI of the Social Security Act as amended by Public Law 98-369 (42 U.S.C. 503 (F) ). It is possible that information concerning your filing history could be accessed by other state, municipal, or federal agencies involved in an income and eligibility verification system. USES: The information required will be used by the Employment Security Division to access wage records and process your application or claim.

AUTHORITY: The Connecticut State Labor Department, Employment Security Division is empowered to solicit this information under the authority of Conn. Statute, Sections 31-222 and 31-254 as supplemented by Section 31-222-8 of the Unemployment Compensation Regulations. EFFECTS OF NON-DISCLOSURE: Disclosure of the requested information is voluntary; however, failure to disclose this information will preclude processing of your claim. PURPOSE: The information requested by this form is considered relevant and necessary to determine entitlement of the services and benefits for which you have applied.

V

SPOUSE DEPENDENCY ALLOWANCE PROGRAM

You may claim a dependency allowance for a non-working spouse (as defined by regulation) who lives with you in the same household.

I certify that my spouse, here named, lives with me in the same household, is

currently unemployed, and:

(CHECK ONE)

Enter your spouse's name only if you checked box 1, 2 or 3.

First

Middle Init.

Last

1. Has not worked in the last three months

3. is pregnant

2. Has a mental or physical disability that is expected to prevent employment and to continue for a long or indefinite period of time.

Spouse's Social Security No.

Is your spouse filing for

Yes No

Unemployment Compensation?

VI

CHILD DEPENDENCY ALLOWANCE

PROGRAM

CAUTION: Complete this section ONLY if you wish to claim an allowance and are the whole or main support of the children.

ALL QUESTIONS IN THIS SECTION MUST BE ANSWERED IN ORDER TO DETERMINE ELIGIBILITY FOR DEPENDENCY ALLOWANCE. If children do not live with you, you MUST present proof of support (cancelled checks, receipts, etc.) for the last three months.

I certify that I am the whole or main support of my children or stepchildren, or children for whom I have assumed parental responsibility who:

1. are under 18 years of age, or 2. are under 21 and a full-time student,(s), or 3. have a mental or physical disability.

ENTER FIRST AND LAST NAME OF YOUR DEPENDENT CHILDREN

Relationship

Town or City and State where Birth is recorded

Date of Birth

Mo. Day

Yr.

Lives with you Check Handicapped

One Check One

IF 18 OR OVER

Name of School Attending

Dates of Attendance

YN YN

Y N

Y N

YN YN

YN YN

YN YN

1. What is your weekly income?

2. What is your spouse's weekly income?

3. Do you receive any contributions from any other source for child support? Yes No

4. If the child does not live with you, how much do you contribute to

support? $

. What is the amount of contribution from

other sources? $.

If yes, how much? $

Child's Name

MY SIGNATURE ON THE FACE OF THIS FORM CERTIFIES THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT AND THAT I AM THE WHOLE OR MAIN

SUPPORT OF THE CHILDREN LISTED ABOVE. I UNDERSTAND THAT MY DEPENDENCY ALLOWANCE CLAIM MAY BE AUDITED AND I MAY BE REQUIRED TO

ESTABLISH PROOF OF ENTITLEMENT.

VII

3. Week ENTER DATES WORKED

TOTAL NUMBER

TOTAL GROSS

1. Did you work, do you expect to work, or was work available to you from any employer other than the one listed in Section III on

(Sun. - Sat

DURING EACH WEEK SINCE DAY OF SEPARATION

OF HOURS WORKED

EARNINGS

the front side of this form?

YES No

Week 1

WEEKLY BENEFIT

CLAIM

If yes, complete items 2 and 3. If you do not know your total gross earnings for item 3, check here:

2. EMPLOYER'S NAME

EMPLOYER'S ADDRESS

Week 2 Week 3 Week 4 Week 5 Week 6

VIII

OTHER EMPLOYMENT IN PAST 6 MONTHS OR MILITARY OR

FEDERAL EMPLOYMENT IN PAST 24 MONTHS

4. I certify that I have been or will be temporarily unemployed during the period of time listed in Section III of this application. All earnings or wages which I have received or expect to receive from this employer are reported in Section III. Wages or earnings received or to be received from any other employer are indicated in the above Section. I understand that if I return to work prior to the date listed on this form or if I suffer an illness or injury that renders me unavailable for work, I must notify the Unemployment Compensation Department. I realize that the law provides penalties for false statements made to obtain benefits.

SIGNED (Claimant) __________________________________________________________________________________ DATE____________________________________

EMPLOYER NAME

REASON FOR SEPARATION OR STILL EMPLOYED

10X MET?

YES

NO (JOB CENTER USE)

ADDRESS

DATES OF EMPLOYMENT

Per Claimant

$____________ EARNINGS

From

______________ EMPLOYER

EMPLOYER NAME

REASON FOR SEPARATION OR STILL EMPLOYED

10X MET?

YES

NO

ADDRESS

DATES OF EMPLOYMENT

Per Claimant

$____________ EARNINGS

From

______________ EMPLOYER

Clear Form

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