- Form Es-935claimant'S Affidavit Form Of Federal Civilian Services - Wages And Reason For Separation
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1STATE OF NEVADA
DEPARTMENT OF EMPLOYMENT, TRAINING AND REHABILITATION
EMPLOYMENT SECURITY DIVISION
CLAIMANT’S AFFIDAVIT OF FEDERAL CIVILIAN SERVICES,
WAGES AND REASON FOR SEPARATION
1. Agent State 032
LO #
2.
Name (Last, First, MI)
3.
SSN
4. Type of Claim
New
Additional
5. Date Filed
6.
Employer (Federal Agency)
7.
Place of Employment
8.
Dates of Employment
City
From:
To:
County
State
Gross Wages Received From the Above Agency (Complete Only if a New Claim)
10. Documentary Evidence (Submitted by the
FOR THE BASE AND LAG PERIODS
claimant showing Federal Civilian
QUARTER ENDING
GROSS WAGES
HOURS WORKED
WEEKS WORKED
Employment)
$
MAIL CLAIMANTS- Send in with this form
copies of all papers you have showing that you
$
worked for the listed Federal Agency. This
includes SF-50, W-2 forms, pay stubs, leave and
$
earnings statements, payroll change slips or
$
other official documents. These copies become
part of your official record. Please do NOT send
$
originals unless absolutely necessary; originals
will be returned to you.
$
11. Lump Sum Payments Received for Terminal Annual Leave
A. Amount of Payment
B. Date of Payment
C. Amount of Leave
D. Effective Period of Terminal Leave
$
From
To
$
From
To
12. Severance Pay—Is claimant entitled to receive severance pay provided by Section 9 of Public Law 89-301, other Federal law or
agency-employee agreement?
Yes
No
13. Reason for Separation
I, the claimant, understand: 1) That penalties are provided by law for an individual making false statements to obtain benefits; 2) That any
determination based on this affidavit is not final; 3) That it is subject to correction upon receipt of wage and separation information from the Federal
Agency for which I worked; 4) That benefit payments made as a result of such determination may have to be adjusted on the basis of information
furnished by the Federal Agency; 5) That any amount overpaid may have to be repaid or offset against future benefits.
I, THE CLAIMANT, SWEAR OR AFFIRM THAT THE ABOVE STATEMENTS, TO THE BEST OF MY KNOWLEDGE
OR BELIEF, ARE TRUE AND CORRECT.
SIGNATURE OF CLAIMANT
Date Signed
Department Representative
Return this form to:
State of Nevada
Employment Security Division
rd
500 E. 3
St. Attn: Benefits Monetary Unit
Carson City, NV 89713
OMB Control Number 1205-0179
ES-935 (Rev 12/00)
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