Form Ub-400 - Shared Work Plan Application - Arizona Department Of Economic Security
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1UB-400 (1-98)
MAIL TO:
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
SPECIAL PROGRAMS UNIT 918B-3
PO BOX 6666
PHOENIX ARIZONA 85005-6666
SHARED WORK PLAN APPLICATION
AGENCY USE ONLY (Plan No)
Please TYPE or PRINT in black ink.
1. EMPLOYING UNIT NAME
2. U.I. EMPLOYER ACCOUNT NO.
3. BUSINESS NAME (Enter “same” if same as item #1)
4. BUSINESS PHONE NO.
)
5. MAILING ADDRESS (No., Street or PO Box, City, State, Zip
EMAIL:
6. ON WHAT DATE (must be a Sunday) DO YOU WANT THIS PLAN TO BECOME EFFECTIVE
7. NUMBER OF EMPLOYEES TO BE COVERED BY THE PLAN AS
LISTED ON THE PARTICIPANT LISTING
8. MAIN ARIZONA WORK LOCATION OF EMPLOYEES LISTED ON THIS PLAN
Street _______________________________ County _______________________ ZIP ______________ Phone No. ______________________
!
!
9. Will the fringe benefits of the employees listed on this plan be affected when their hours are reduced?
YES
NO
If yes, how? (Please specify)
10. List each collective bargaining representative(s) for any employee(s) covered by this plan:
UNION NAME
LOCAL
UNION OFFICIAL
TITLE
A.
B.
C.
I APPROVE OF THIS SHARED WORK PLAN
SIGNATURE (Official A)
DATE
SIGNATURE (Official B)
DATE
SIGNATURE (Official C)
DATE
11. EMPLOYER CERTIFICATION
Each employee listed on this plan has been paid at least $1,000 in wages payable from this business during the six-month
!
500
period immediately preceding the date of this plan.
During the effective period of this plan, instead of layoffs there may be a reduction(s) in the total normal weekly hours for
!
the employees specified on the attached Participant Listing. If a reduction occurs, the total normal weekly work hours
reduced will be at least as many as would have occurred with a layoff.
I have read and understand the SHARED WORK INFORMATION AND APPLICATION INSTRUCTIONS. I am aware of the
!
potential effects on my Unemployment Insurance account (experience-rated or reimbursable) if Shared Work benefits are
paid to my employees.
OWNER, PARTNER OR CORPORATE OFFICER'S NAME (Type or print)
TITLE
OWNER, PARTNER OR CORPORATE OFFICER'S SIGNATURE
DATE SUBMITTED
FOR DEPARTMENT USE ONLY - DO NOT COMPLETE BELOW THIS LINE
12. PLAN DETERMINATION
!
!
I recommend
Approval
Disapproval
REASON(S)
APPROVED BY
TITLE
DATE
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