Unemployment Insurance Termination Report Form
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UNEMPLOYMENT INSURANCE TERMINATION REPORT
Forward to your local Unemployment
Insurance Coordinator
U5602 (R2/04) University of California Human Resources and Benefits
To be completed by the department(s) for all separating employees.
Please print or type and complete all items accurately. Failure to do so may subject the University to a penalty. Send completed form directly to the
Unemployment Insurance Coordinator, local Personnel Office. Do not route with other separation forms. Delay in submission could affect benets.
PERSONAL INFORMATION
NAME (Last, First, Middle Initial)
SOCIAL SECURITY NUMBER
EMPLOYEE ID NUMBER
DATE OF SEPARATION
CAMPUS
DEPARTMENT NAMES
DATE OF HIRE
LAST DAY ACTUALLY WORKED
U.C. STUDENT STATUS
FULL ACCOUNTING UNIT(S)
PAYROLL TITLES
TITLE CODES AT SEPARATION
PRIMARY FUNDING SOURCE
(Check only one box)
Not Registered
19900 Funds
Undergraduate
Federal Funds
Graduate
Hospital Funds
Other
All other funds
REASON FOR TERMINATION (This question must be answered accurately in all cases.)
Was termination requested or suggested by the University?
Yes
No
REASON FOR SEPARATION Provide details in “Explanation” below.
Resignation
(AA) To accept another job*
(AE) Pregnancy–did not desire leave
(AI) Military Service
(AM) Moved out of area
(AB) To look for another job
(AF) Family and/or child care
(AJ) Failed to return from leave
(AN) No reason given
(AC) Self-employment
(AG) Health
(AK) Other (explain below)
(EC) Quit without notice
(AD) Dissatised with job
(AH) To attend school
Retirement
Expiration of Appointment
Release
(RA) Retirement
(BA) Grant/contract expired
(CB) Limited employee
(RD) Retirement—compulsory for SMGs and regents’ officers
(BB) Appointment/contract appt. expired
(CD) Casual restricted appointment
(RF) Retirement—faculty
(BC) Visa/work authorization expired
(CE) Graduation/no longer student
(CC) Other casual employee (on call)
Indefinite Layoff
Termination—Due to:
(CA) Layoff w/recall/rehire rights
(CH) Layoff, severance & rehire/recall rights
(EA) Lack of performance
(EB) Misconduct
(CG) Layoff w/severance
(CI) Layoff, no severance or recall
(ED) Job abandonment
(EE) Never started employment
(EF) No longer certied/licensed
(EG) Do not rehire—settlement
(employee agrees not to return)
Medical Separation
Change to Emeritus Status
Released—Before attaining regular status
(GA)
(JA)
(DA)
Death
Termination from Senior Management, Per Diem Classes and Coach/Related Professional
(KA) Give date and name of survivor
(LA) Other termination
(CF) Per diem release
Explanation:
*
If resigning to accept other employment, provide name of next employer _____________________________________________________
(MO/DY/YR)
(MO/DY/YR)
Layoff/Furlough
Temporary Layoff
Give dates:
From ______________________ To __________________________
Furlough
Give dates:
From ______________________ To __________________________
SIGNATURES
EMPLOYEE
DATE
DEPARTMENT HEAD
DATE
PREPARED BY
DATE
EXTENSION
For Unemployment Insurance records only. Not for use in employment references.
RETN: 3 years after separation
SEE REVERSE FOR PRIVACY NOTIFICATIONS
Other copies: 0–3 years after separation
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