Form Uc-61 - Section F - Unemployment Notice
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1STATE OF CONNECTICUT - DEPARTMENT OF LABOR
UC-61 (Rev. 4/15)
IMPORTANTE: TENGA ESTO TRADUCIDO INMEDIATAMENTE
SECTION F - UNEMPLOYMENT NOTICE
INSTRUCTIONS TO EMPLOYER:
It is your responsibility to give this entire packet to the separating employee at the time of separation, regardless of
the reason for separation (see Section L below). If it is not possible to give this packet to the employee at the time of
separation, then mail the packet to the employee’s last known address.
DO NOT send a copy to the Department of Labor.
PLEASE BE SURE THAT ALL THE INFORMATION ENTERED BELOW IS CORRECT
A.
EMPLOYER CONNECTICUT REGISTRATION NUMBER
(If unsure, call Employer Status Unit at 860-263-6550, all
-
-
other questions should be directed to Claims Exam at
860-263-6635.)
B. COMPANY NAME
C. COMPANY ADDRESS Please note: all fact finding hearing notices will be sent to this address.
D. EMPLOYEE NAME
E. SOCIAL SECURITY NUMBER
-
-
F. NCCI CODE (for use only if this employee was employed in a CONSTRUCTION TRADE)
G. START DATE
H. LAST DAY
I. RETURN
/
/
/
/
/
/
WORKED
TO WORK
DATE
(if
definite)
J. YEAR TO DATE
K.
WAGES FOR THE LAST WEEK OF WORK IF LESS THAN A FULL
$
$
EARNINGS
WEEK
(Sunday - Saturday)
Lack of Work
Voluntary Leaving
Discharge/ Suspension
Leave of
L
. REASON FOR
Absence
UNEMPLOYMENT
__________________________________________________________________________
Other
M.
DID OR WILL THIS EMPLOYEE RECEIVE DISMISSAL PAY (i.e. TYPE:
YES
NO
1. SEVERANCE, 2. VACATION, 3. HOLIDAY, 4. OTHER) AFTER LAST DAY OF WORK?
If yes, what type?
No. of hours/days covered
Amount
Dates Covered
EMPLOYER SIGNATURE
TITLE
DATE
TELEPHONE NUMBER
FAX NUMBER
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