Low Earnings And Partial Claim Report Form - South Carolina Employment Security Commission
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1UCB-114…Revised 7/01
Catalog#: 08195
1. LOCAL OFFICE NUMBER
SOUTH CAROLINA EMPLOYMENT SECURITY COMMISSION
LOW EARNINGS AND PARTIAL CLAIM REPORT
PLEASE PRINT………
………
USE BLACK INK WHEN COMPLETING THIS FORM
(See reverse side for instructions.)
THIS IS TO CERTIFY THAT THIS WORKER WAS EMPLOYED DURING CLAIM WEEK ENDING…
2. WORKER'S NAME
6.
SOCIAL SECURITY NUMBER
NAME WORKED UNDER (if different)
7.
CLAIM WEEK ENDING DATE
3. MAILING ADDRESS
Month
Day
Year
4. CITY
STATE
ZIP
q
q
8.
FEMALE
MALE
ETHNIC CODE
RACE CODE
q
q
1. Hispanic or Latino
1. White
5. COUNTY of RESIDENCE (see reverse side for name and code)
q
q
2. Not Hispanic or
2. Black or African American
q
Latino
3. Asian
9. EMPLOYER ACCOUNT NUMBER
q
q
3. Information Not
4. American Indian or
Available
Alaska Native
q
5. Native Hawaiian or Other
10. EMPLOYER NAME and TELEPHONE NUMBER
Pacific Islander
q
6. Information Not Available
11. TOTAL OF WAGES AND OTHER EARNINGS DURING THIS WEEK.
(This includes earnings made with any other employer.)
12. TOTAL MONTHLY PENSION AMOUNT RECEIVED.
(EXCLUDE SOCIAL SECURITY)
13. IS THIS WORKER A CORPORATE OFFICIAL
14. IS THIS WORKER THE CHILD (less than 18 years old),
q
q
SPOUSE, OR PARENT OF EMPLOYER?
OF THIS BUSINESS?
YES
NO
q
q
(Proprietorships/Partnerships Only)
YES
NO
TO BE COMPLETED BY WORKER
q
q
15.
HAS YOUR ADDRESS CHANGED SINCE YOU LAST FILED FOR UNEMPLOYMENT INSURANCE BENEFITS?
YES
NO
(It is important that you verify your address in 3, 4, and 5.)
q
q
16.
I CERTIFY UNDER PENALTY OF PERJURY THAT I AM A CITIZEN OR NATIONAL OF THE UNITED STATES.
YES
NO
(If NO, complete Number 17.)
q
q
17.
I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT I AM IN A SATISFACTORY IMMIGRATION STATUS.
YES
NO
18.
WORKER'S TELEPHONE NUMBER:
ITEM 11 ABOVE MUST SHOW TOTAL EARNINGS FROM THIS EMPLOYER AS WELL AS ANY OTHER EMPLOYER.
WORKER'S CERTIFICATION: I certify that I was able to work and available for work during the week claimed. I certify that the answers on this form
are true and correct to the best of my knowledge. I understand that the law provides penalties for making false statements to obtain or increase benefits.
EMPLOYER'S CERTIFICATION: I certify that for the period covered by this claim, the worker was employed and accepted all available work.
WORKER'S SIGNATURE
DATE OF PREPARATION
EMPLOYER'S SIGNATURE
RETURN ORIGINAL FORM ONLY
THIS FORM WILL BE MACHINE READ………DO NOT FOLD OR BEND
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