Form Ncui 501 - Benefit Claim For Attached Worker
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1Employment Security Commission of North Carolina
Unemployment Insurance Division
Benefit Claim for Attached Worker
(Please read instructions on the following page. Please type all information.)
WORKER INFORMATION
1. FIRST NAME
MI
LAST NAME
2. SOCIAL SECURITY NUMBER
3. MAILING ADDRESS
CITY
STATE
ZIP CODE
4. COUNTY OF RESIDENCE
6. SEX
5. HISPANIC/LATINO
(0) No
(1) Yes
(9) Unknown
CODE
5a. RACE
7. DATE OF BIRTH
(1) WHITE
(2) BLACK
(3)
(4) ASIAN
(5) PACIFIC
(6) MULTIPLE
(7) OTHER
AMERICAN
ISLANDER /
INDIAN /
HAWAIIAN
ALASKAN
MM / DD / YYYY
NATIVE
8. ARE YOU
9. RETIREMENT
10. DURING THE PAST 2 YEARS
11. DURING THE PAST 2
12. DURING THE PAST 2
Y
Y
Y
Y
Y
A U.S.
PENSION
HAVE YOU SERVED IN THE US
YEARS HAVE YOU
YEARS HAVE YOU
N
N
N
N
N
CITIZEN?
MILITARY?
WORKED AS A
WORKED IN
CIVILIAN FOR THE
ANOTHER STATE?
U.S. GOVERNMENT?
(If “NO” FOR ITEM 8, OR “YES” FOR ITEM 9, COMPLETE FORM AND
(If “YES” FOR 10-12, COMPLETE THISD FORM AND GIVE TO
GIVE TO EMPLOYEE TO TAKE TO NEAREST ESC OFFICE.)
EMPLOYEE TO TAKE TO NEAREST ESC OFFICE.)
13. PAYROLL WEEK ENDING
14. TOTAL EARNINGS FROM ALL SOURCES
$
MM DD YYYY
EMPLOYER INFORMATION
15. EMPLOYER ACCOUNT NO.
16. EMPLOYER BUSINESS NAME
17. EMPLOYER TELEPHONE NO.
18. MAILING ADDRESS
CITY
STATE
ZIP CODE
19. IF YOUR EMPLOYEE DID NOT WORK ALL SCHEDULED HOURS IN THE WEEK LISTED IN ITEM 14, PLEASE EXPLAIN:
COMPLETE FORM AND GIVE TO EMPLOYEE TO TAKE TO EMPLOYMENT SECURITY COMMISSION OFFICE.
20. EMPLOYER'S CERTIFICATION: I CERTIFY THIS BENEFIT CLAIM WAS COMPLETED IN ACCORDANCE WITH THE REGULATION
PRESCRIBED BY THE NORTH CAROLINA EMPLOYMENT SECURITY LAW.
DATE
EMPLOYER SIGNATURE
EMPLOYER TITLE
NCUI 501 (Revised 04/2008)
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