Form Uc-62v - Vacation Shutdown New Claim For Unemployment Compensation Benefits
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1
2DEPARTMENT OF LABOR
EMPLOYMENT SECURITY DIVISION
VACATION SHUTDOWN
STATE OF CONNECTICUT
NEW CLAIM
_
_
FOR UNEMPLOYMENT
Print your Social Security No.
IMPORTANTE: TENGA
here. (Be sure to copy from
COMPENSATION BENEFITS
ESTO TRADUCIDO
your Soc. Sec. Card)
Form UC-62V (Rev 9/14)
INMEDIATAMENTE
(One Number Per Block)
DATE OF BIRTH
SEX
NAME (Please Print)
First
(Middle Init.)
(Last)
I
Mo
Day
Year
M
F
CLAIMANT
MAILING ADDRESS (No. & Street) or (P.O. Box Number)
MARITAL STATUS
INFORMATION
Sing.
Marr.
Wid.
Sep.
Div.
1.
2.
3.
4.
5.
Town you live in if different from mailing address
CITY
(DO NOT ABBREVIATE)
STATE
ZIP
TELEPHONE NO.
YES
NO
YES NO
Are you a U.S. Citizen? If No, I certify that I am in satisfactory
In the last 24 months have you:
Complete form by
alien status. Attach copy of front and back of card and write alien
Friday of the first
number here.
Worked in another state? If yes, what state(s)?
week which you
Are you able and available for full-time work?
Worked for a federal agency? If Yes, complete section VIII
claim benefits and
return to:
Did you start receiving a pension or other retirement benefits
within the last 24 months? If yes, name of employer:
Served in the Armed Forces? If Yes, complete section VIII
Claims Exam Unit
Dept of Labor
Worked for an educational institution?
Are you attending school or training?
200 Folly Brook Blvd
Been a corporate officer, self-employed, owner of a business?
Wethersfield, CT
Are you a construction worker?
06109
Have you worked (either full or part-time) for any other employer
Worked under another name? (If “Yes,” print name here.)
in the last 6 months? (if YES, complete Section VIII on back)
TAX
I ELECT TO HAVE FEDERAL (10%) AND CT STATE (3%) INCOME TAX WITHHELD FROM MY UNEMPLOYMENT BENEFITS
YES
NO
WITHHOLDING
I hereby serve notice of intent to apply for unemployment benefits. I request and agree to accept the establishment of a Benefit Year, if none is in effect. I authorize
the release to the Department of Labor of such wage and other information that may be required to determine my eligibility for Unemployment Compensation Benefits.
See
I certify that the information provided on both the front and back of this form is true and correct. I understand that a false statement or failure to disclose material facts
Disclosure
AUTHORIZATION
to obtain benefits is a violation of the law.
Information
on reverse of
form
SIGNED (Claimant)
DATE
COMPLETE THE OTHER SIDE IF YOU WISH TO FILE FOR DEPENDENCY ALLOWANCE OR IF YOU WORKED FOR A FEDERAL OR MILITARY EMPLOYER
Effective Date
Date Reported
Tax With.
S.A.C.
Spouse
RNO
Occ. Code
No.
II.
Mo.
Day
Year
Mo.
Day
Year
Dep.
Allow.
YES
NO
Yes
No
FOR
Branch of Military Service
UCX Employer Number
Mass Layoff
UC-893
ES-931
ES-973
1B-4
FFR Issue No.
PRIM.
01. Vol. Leaving
X
OFFICE
1.
02. Vol. Retirement
2.
3.
4.
5.
03. Student Quit
PENSIONING EMPLOYER
PAYMENT ALLOC: Type Code: 1. Sev. 2. Vac. 3. Hol. 4. Other
04. Willful misconduct or felonious
USE
Name
AMOUNTS
conduct
Type
Allocated to
05. Refusal of Rehire
Code
Week Ending
Stat
Non stat
06. Refusal of Work
SEC.
ONLY
Street
Mo.
Day
Year
07. Able Available
08. Reasonable Eff.
09. Sec. Ben. Year
City
(5 X WBR or $300)
10. Disq. Income
11. Deduct. Income (pot. earn, etc.)
State
12. Student Avail.
13. Invalid Filing
15. Labor Dispute
SEC. EMP FFR
16. FSC. TRA
DATE UC-952
Mo
Day
Year
Yes
No
20. Monetary
MAILED
PROGRAM
(inc. dep. allow)
21. 10 x WBR (quit)
Reg. #
C.S.R.
J.C. Number
22. 10 x WBR (discharge)
0
23. 40 x WBR (vol. Ret.)
UV
nd
24. 5 x WBR or $300 (2
ben. yr.)
25. Sec. 31-227(d)(e)(f)
REMARKS
31. 6 x WBR (Refusal of Rehire/Work)
32. 4 x 4 (Requal wage FSC, TRA)
1. CT. REGISTRATION NO.
3. COMPANY NAME, STREET, TOWN, SATE AND ZIP CODE
4. EMPLOYEE’S NAME
III.
ADDRESS TO WHICH NOTICE OF FACT FINDING
HEARING WILL BE SENT.
EMPLOYER
2. NCCI CODE
5. EMPLOYEE’S SOCIAL SECURITY NO.
INFORMATION
7. LENGTH OF MOST RECENT
6. WAGES FOR LAST WEEK OF WORK FROM SUNDAY TO
(TO BE
PERIOD OF EMPLOYMENT
DATE LAST WORKED (If less than full week)
COMPLETED BY
NO. OF HOURS
WAGES
YRS
MOS
DAYS
EMPLOYER)
8. DATE LAST WORKED
9. RETURN TO WORK DATE
10. Will any payment be made or has any payment been
No
made which is not wages for work actually performed
Use this form if
during period of unemployment?
Yes
there is a DEFINITE
12. TYPE OF PAYMENT (If yes to # 10)
13. LAST DATE COVERED BY PAYMENT
return to work date
11. REASON FOR UNEMPLOYMENT
1. Severance
2. Vacation
(#9) that is 6 weeks
3. Holiday
4. Other
or less from the date
LACK OF WORK – TEMPORARY COMPANY SHUTDOWN
Type
No. of Hours/Days Covered
AMOUNT
DATES COVERED
last worked (#8).
Also, there should be
14. I certify that the information in this notice is true and correct
no other issues
involved. Otherwise,
please use the
SIGNATURE AND TITLE OF OFFICIAL
DATE
Separation Packet -
Office Use
Form UC-62T.
Claimant Stmt.
(
)
Yes
TELEPHONE NUMBER
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