Form 60-0154 - Notice Form Of Separation Or Refusal Of Work Under Conditions That May Disqualify - Iowa Workforce Development
ADVERTISEMENT
1
2Instructions On Reverse
NOTICE OF SEPARATION OR REFUSAL OF WORK UNDER CONDITIONS THAT MAY DISQUALIFY 60-0154 (2-97)
WORKER’S NAME
SOCIAL SECURITY NUMBER
(Date) Separation or refusal to work
Month
Day
Year
3.
1.
2.
4.
EMPLOYMENT WAS TERMINATED FOR THE REASON CHECKED
Refused suitable
Voluntary
Discharged for
Left to take other
work or recall
quit
misconduct in
employment
The Protest Box and Complete Separation or Refusal of Work Date
to work
MUST BE INDICATED on all responses.
connection
with work
IOWA ACCOUNT NUMBER
If Applicable, Location Code
The separation information you provide must be
INTERVIEW INFORMATION
Certified Correct By Signing and Completing the
If a fact-finding interview is necessary, you will be
EMPLOYER
Signature Box.
scheduled for an interview by telephone unless it is
CERTIFIED CORRECT BY (BUSINESS Signature Requested)
impractical to do so.
EMPLOYER ADDRESS (Street, City, State and Zip Code)
NAME OF PERSON who will participate in a fact-
finding interview for this employer.
PRINT LEGIBLY
TITLE
Date
Name _______________________________________
Title ________________________________________
Telephone number for fact-finding interview
FOR DEPARTMENT USE ONLY:
O.C. _________ L.O.# _____________
(include area code) _________________________________
SUPPORTING DOCUMENTS may be submitted with this form for
consideration at the telephone fact-finding.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 60-0154 - Notice Of Separation Or Refusal Of Work Under Conditions That May Disqualify - 1996
Legal
Form 68-0092 - Declaration Of Power Of Attorney Or Authorized Representative - Iowa Workforce Development Unemployment Insurance (ui) Tax Bureau
Legal
Related Categories
Parent category: Legal