WORK SEARCH RECORD - Pennsylvania
DEPARTMENT OF LABOR & INDUSTRY OFFICE OF UNEMPLOYMENT COMPENSATION BENEFITS
WORK SEARCH RECORD
WORK SEARCH RECORD FOR WEEK BEGINNING SUNDAY
THROUGH SATURDAY
To be eligible for UC benefits, complete the work search record below. Refer to your Pennsylvania UC Handbook (Form UCP-1) or go to uc. for complete instructions or to print additional
copies of this form. If you are working part-time, and earning more than your Partial Benefit Credit, initial here
.
JOB APPLICATIONS/INTERVIEWS
#1 Date of Application Employer Employer Contact Name Employer Phone/Email How did you apply for the job Results
#2 Date of Application Employer Employer Contact Name Employer Phone/Email How did you apply for the job Results
#3 Date of Application Employer Employer Contact Name Employer Phone/Email How did you apply for the job Results
or Date of Interview or Date of Interview or Date of Interview
WORK SEARCH ACTIVITY Date of Activity Type of Activity Location of Activity Contact Name Contact Phone/Email Date of Activity Type of Activity Location of Activity Contact Name Contact Phone/Email Date of Activity Type of Activity Location of Activity Contact Name Contact Phone/Email
EXEMPTION Written Date of Recall (attach copy) Union Hiring Hall Reemployment Services & Eligibility Assessment (RESEA) participants
Name of Employer, Union Hiring Hall or Training Program
Contact Name and Phone Number
Shared Work program participants
Trade Reduction Act participants
I certify that all information I have provided in this document is correct and complete. I acknowledge that false statements in this document are punishable pursuant to 18 Pa.C.S. ?4904, relating to unsworn falsification to authorities.
First Name
M.I. Last Name
Social Security Number XXX-XX-
(last 4 digits)
Signature
Date
A person who knowingly makes a false statement or knowingly withholds information to obtain UC benefits commits a criminal offense under Section 801 of the UC Law, 43 P.S. ?871, and may be subject to a fine, imprisonment, restitution and loss of future benefits.
UC-304 REV 09-22 (Page 1)
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