Form Me. B-9.2 - Initial Claim Form - Mail - 2003

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MAINE DEPARTMENT OF LABOR
INITIAL CLAIM FORM - MAIL
Bureau of Unemployment Compensation
1. Name
2. Social Security Number
(First)
(Middle)
(Last)
3. Mailing Address
4. Telephone
(No. Street or Rural Route)
(City or Town)
(State - ZIP Code)
5.
This Department provides accommodations for persons with disabilities. If you require special services, please
check:
[ ] Reader
[ ] Interpreter
[ ] Other (specify)________________________________________
6.
If you are a military veteran, please enter dates of service:
Entered: Month______Day______Year______
Released: Month______Day______Year______
Military Service Branch___________________________________________________________________________
7.
Do you expect to be recalled by your former employer?
0 [ ] Currently Working
1 [ ] YES, Date of Recall is_________________________
2 [ ] YES, No Specific Date
3 [ ] NO
8.
School Status:
[ ] In School;
[ ] Not in School
9.
In the last 10 years, what job have you done the most?__________________________________________________
How much experience do you have in this job?
____________years
____________months
Occupation that you wish to seek work in if not the same as above:________________________________________
10. Hired through Union Hall?....................................................................................................................[ ] YES [ ] NO
11. Are you receiving social security or any type of retirement pension? ..................................................[ ] YES [ ] NO
12. Have you received or are you entitled to receive any severance, terminal or dismissal wages,
wages in lieu of notice, vacation pay, holiday pay, or bonus payments?.............................................[ ] YES [ ] NO
If “YES,” Type(s) of Payment________________Gross amount___________________When paid_____________
Attach additional sheet if needed.
13. DEPENDENCY SECTION: You may be entitled to an allowance for each dependent child up to ½
of your weekly benefit amount. If you are presently providing more than ½ of the cost of support
for a dependent and your spouse, who is contributing some support for the dependent, is not
employed full-time, please check here to request a Dependency form. ..............................................[ ] YES
>>Are you required to pay child support to a court or child support enforcement agency? .........................[ ] YES [ ] NO
14. Resident Town___________________Date of Birth_______________ [ ] Male
[ ] Female
School Yrs. Completed________
Handicapped/Disabled? [ ] YES [ ] NO
# of People in Family________
Family Responsibility: [ ] Principal Earner; [ ] Secondary Earner; [ ] Live Alone
[ ] Married [ ] Single
[ ] Other
>>I attest, under penalties of perjury, that I am:
[ ] A citizen of the United States
[ ] An alien lawfully admitted for permanent residence. (Alien No. A-_______________________)
[ ] An alien authorized by the Immigration and Naturalization Service to work in the U.S.
Alien No.___________or Admission No.__________Exp. Date of Employment Auth. if any___________________
15. OPTIONAL [ ] White; [ ] Black; [ ] Hispanic; [ ] Asian/Pacific Island; [ ] Indian/Alaskan-Native;
16. WORK HISTORY:
Current or Last Employer (Company Name)
Job Title
Address of Work Location
Job Began
Duration
Job Ended
Salary: $_________________ per [ ] Hour;
[ ] Day; [ ] Week; [ ] Year; [ ] Other
Normal Hours per Week Worked ____________
Reason for Separation:
OFFICE USE: Employer
Number
1 [ ] Lack
2 [ ] Left
3 [ ] Discharge
4 [ ] Labor
5 [ ] Currently
6 [ ] On a Leave
of Work
Voluntarily
or Suspension
Dispute
Employed
of Absence
Me. B-9.2 Web (rev. 12/03)
> > > CONTINUED ON REVERSE < < <

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