Form Uc-62v - Vacation Shutdown New Claim For Unemployment Compensation Benefits Page 2

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Information concerning an individual’s unemployment compensation claim

AUTHORITY: The Connecticut State Labor Department, Employment Security

may be disclosed, under certain circumstances, to other governmental

Division is empowered to solicit this information under the authority of Conn.

agencies pursuant to Title XI of the Social Security Act as amended by

Statute, Sections 31-222 and 31-254 as supplemented by Section 31-222-8 of the

Public Law 98-369 (42 U.S.C. 503 (F) ).

Unemployment Compensation Regulations.

It is possible that information concerning your filing history could be

EFFECTS OF NON-DISCLOSURE: Disclosure of the requested information is

accessed by other state, municipal, or federal agencies involved in an

voluntary; however, failure to disclose this information will preclude processing of

income and eligibility verification system.

your claim.

DISCLOSURE

USES: The information required will be used by the Employment Security

PURPOSE: The information requested by this form is considered relevant and

INFORMATIO

Division to access wage records and process your application or claim.

necessary to determine entitlement of the services and benefits for which you

have applied.

You may claim a dependency allowance for a non-working spouse (as defined by regulation) who lives with you in the same household.

Enter your spouse’s name only if you checked box 1, 2 or 3.

I certify that my spouse, here named, lives with me in the same household, is

First

Middle Init.

Last

currently unemployed, and:

(CHECK ONE)

SPOUSE

DEPENDENCY

Has not worked in the last three months

is pregnant

Is your spouse filing for

Yes

Spouse’s Social Security No.

ALLOWANCE

Unemployment Compensation?

Has a mental or physical disability that is expected to prevent

PROGRAM

employment and to continue for a long or indefinite period of time.

CAUTION: Complete this section ONLY if you wish to claim an allowance and are the whole or main support of the children.

ALL QUESTIONS IN THIS SECTION MUST BE ANSWERED IN ORDER TO DETERMINE ELIGIBILITY FOR DEPENDENCY ALLOWANCE.

If children do not live with you, you MUST present proof of support (cancelled checks, receipts, etc.) for the last three months.

CHILD

I certify that I am the whole or main support of my children or stepchildren, or children for whom I have assumed parental

DEPENDENCY

responsibility who:

ALLOWANCE

1. are under 18 years of age, or

PROGRA

2. are under 21 and a full-time student,(s), or

3. have a mental or physical disability.

Town or City and State

Date of Birth

IF 18 OR OVER

Lives with

ENTER FIRST AND LAST NAME OF YOUR

Relationship

where Birth is recorded

you Check

Handicapped

Name of School Attending

Dates of Attendance

DEPENDENT CHILDREN

Mo.

Day

Yr.

One

Check One

1. What is your weekly income?

2. What is your spouse’s weekly income?

4. If the child does not live with you, how much do you contribute to

3. Do you receive any contributions from any other source for child

support? $

. What is the amount of contribution from

support?

Yes

other sources? $.

If yes, how much? $

Child’s Name

MY SIGNATURE ON THE FACE OF THIS FORM CERTIFIES THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT AND THAT I AM THE WHOLE OR MAIN

SUPPORT OF THE CHILDREN LISTED ABOVE. I UNDERSTAND THAT MY DEPENDENCY ALLOWANCE CLAIM MAY BE AUDITED AND I MAY BE REQUIRED TO

ESTABLISH PROOF OF ENTITLEMENT.

ENTER DATES WORKED

TOTAL NUMBER

TOTAL GROSS

VII

3. Week

DURING EACH WEEK SINCE

OF HOURS

EARNINGS

1. Did you work, do you expect to work, or was work available to you

(Sun. - Sat

DAY OF SEPARATION

WORKED

from any employer other than the one listed in Section III on

the front side of this form?

YES

Week 1

Week 2

If yes, complete items 2 and 3. If you do not know your total gross

earnings for item 3, check here:

Week 3

WEEKLY

2. EMPLOYER’S NAME

Week 4

BENEFIT

EMPLOYER’S ADDRESS

Week 5

CLAIM

Week 6

4. I certify that I have been or will be temporarily unemployed during the period of time listed in Section III of this application. All earnings or wages

which I have received or expect to receive from this employer are reported in Section III. Wages or earnings received or to be received from any

other employer are indicated in the above Section. I understand that if I return to work prior to the date listed on this form or if I suffer an illness or

injury that renders me unavailable for work, I must notify the Unemployment Compensation Department. I realize that the law provides penalties

for false statements made to obtain benefits.

SIGNED (Claimant) __________________________________________________________________________________ DATE____________________________________

VIII

EMPLOYER NAME

REASON FOR SEPARATION

OR STILL EMPLOYED

10X MET?

YES

NO (JOB CENTER USE)

Per Claimant

OTHER