Form Ib10-A2 - Eligibility Review Notice Page 2
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1
2Work Search Records
Approved Contact Methods: In Person, Resume, Internet, Fax, Telephone, and Email.
Week 1
Beginning Sunday
and Ending Saturday
I did not seek work during this week because:
Dates of Contacts
Employer's Name: Address, Website, E-mail Address or Name & Title of Person Contacted
Contact Method
Position Applied
For
Week 2
Beginning Sunday
and Ending Saturday
I did not seek work during this week because:
Dates of Contacts
Employer's Name: Address, Website, E-mail Address or Name & Title of Person Contacted
Contact Method
Position Applied
For
Week 3
Beginning Sunday
and Ending Saturday
I did not seek work during this week because:
Dates of Contacts
Employer's Name: Address, Website, E-mail Address or Name & Title of Person Contacted
Contact Method
Position Applied
For
I do solemnly affirm under penalty of perjury, that I am the person named herein, and that the information that I have provided, including proof of
identification and the work search record, is true, correct, and complete to the best of my knowledge. I further understand that there are severe
criminal and civil penalties for providing false statements and/or willfully misrepresenting any information to increase or receive unemployment
insurance benefits, and that any information I have provided is subject to verification.
Claimant Signature _________________________________________________________ Date _____________________________________
IB10-A2 Rev (04/2016)
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Parent category: Legal