Application For Unemployment Insurance Form printable pdf download

VERMONT DEPARTMENT OF LABOR

APPLICATION FOR UNEMPLOYMENT INSURANCE

P.O. Box 189, Montpelier, VT 05601-0189

Please print clearly to avoid delays in processing.

SEX

SSN

DIRECT DEPOSIT INFORMATION

NAME (LAST, FIRST, MIDDLE INITIAL)

Bank Routing Number (9 digits)

STREET ADDRESS, P.O. BOX, ETC.

VT. DRIVER'S LICENSE NO.

Account Number (up to 17 digits)

CITY

STATE

ZIP

TELEPHONE NUMBER BIRTHDATE

Mo/Day/Yr

Type of Account

(

)

Checking

Savings

EMPLOYMENT HISTORY

REASON FOR

IF APPLICABLE, RETURN

START DATE

END DATE

TO WORK DATE

PAST 18 MONTHS

FILING

LAST OR CURRENT EMPLOYER (NAME & MAIL ADDRESS)

MO/DAY/YR

QUIT

LAID OFF

FIRED

WORKING PART-TIME

LAST OR CURRENT EMPLOYER (NAME & MAIL ADDRESS)

MO/DAY/YR

QUIT

LAID OFF

FIRED

WORKING PART-TIME

LAST OR CURRENT EMPLOYER (NAME & MAIL ADDRESS)

MO/DAY/YR

QUIT

LAID OFF

FIRED

WORKING PART-TIME

LAST OR CURRENT EMPLOYER (NAME & MAIL ADDRESS)

MO/DAY/YR

QUIT

LAID OFF

FIRED

WORKING PART-TIME

U.S. CITIZEN?

Yes

(If No, Permit No. ____________________________________________________________)

Unemployment benefits is taxable income. Do you want State and Federal taxes subtracted from your unemployment benefits each week?

Yes

Are you a military service veteran?

Yes

You must report to the department receipt of the following types of money. Check all that you will or have received and provide the requested information.

Vacation Pay

Wages in Lieu of Notice

Severance Pay

Pension

$ __________ # hours ____ # wks ____

$ _____________

(Indicate only if you

did not contribute to plan)

Workers' Compensation: Are you or will you receive it? Yes

Have you received it within the past six months? Yes

Please specify which of the following have occurred within the past 18 months? Check all that apply.

Worked in another state (If Yes, what states_______________________)

Served on active duty

Worked for the Federal Government

Worked for a business you owned

Related to the owner of business you worked for

Have you filed for any benefits in this or another state, including Canada within the past 12 months? If Yes, what state? __________

YES

Are you self-employed, attempting to become self-employed, working on a commission basis or engaged in any activities or

YES

hobbies from which you earn money?

Are you currently able and available to accept full-time work?

YES

Are you available for all shifts?

YES

Are you currently attending or planning to attend school or training?

YES

I attest, under penalty of perjury, that all information provided on this form is true. I hereby register for work

and claim benefits. I understand that, once filed, this claim cannot be withdrawn.

__________________________________________________

___________________________________________

Claimant Signature

Date

DEPARTMENT USE ONLY

New

Add

Reopen

Effective Date: __________________

B-65 (1/09)

Program:

STC

Fed Ext.

Initial _____

Date __________________

Application For Unemployment Insurance Form

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