Affidavit of Employment and Wages - Indiana
In order to compute the amount of my weekly entitlement to DISASTER UNEMPLOYMENT ASSISTANCE, I certify I had the following employment, self-employment, and earnings during previous calendar year. Name and Address of Employer (or Self-Employment) Period Employed. Total. Gross/Net* Earnings. Weekly. Wage. Hours. Worked. Weekly. From. To. 1. $ $ 2 ... ................
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