Instructions On Reverse
NOTICE OF SEPARATION OR REFUSAL OF WORK UNDER CONDITIONS THAT MAY DISQUALIFY 60-0154 (2-97)
SOCIAL SECURITY NUMBER
(Date) Separation or refusal to work
EMPLOYMENT WAS TERMINATED FOR THE REASON CHECKED
Left to take other
work or recall
The Protest Box and Complete Separation or Refusal of Work Date
MUST BE INDICATED on all responses.
IOWA ACCOUNT NUMBER
If Applicable, Location Code
The separation information you provide must be
Certified Correct By Signing and Completing the
If a fact-finding interview is necessary, you will be
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.
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.