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Instructions for ES-935

Claimant’s Affidavit of Federal Civilian Services,

Wages and Reason for Separation

The ES-935 is used to establish potential eligibility for unemployment benefits for individuals who worked in a

civilian capacity for the Federal Government. Not all employment with the Federal Government is considered

covered employment and may not be usable to establish a claim for unemployment benefits. If you receive

benefits based on this affidavit and are subsequently found to have not been entitled to the amounts paid, you may

be liable to repay the money you received.

Complete the following boxes and requested information:

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Box 2: Complete your name in the format Last Name, First Name, Middle Initial Example: Public, John Q Not John Q

Public

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Box 3: Complete your social security number. Use digits. If you have more than one social security number, complete the

number you used while working for the Federal Government.

•

Box 6: Complete the Federal Agency shown on your Form SF-8 or SF-50. If you did not receive a Form SF-8 or SF-50 on or

after your separation from employment with the Federal Agency, you may not use the form ES-935 to claim credit for this

employment. You must wait for the Federal Agency to respond to the notice of claim filing to be determined potentially

eligible. You must enclose a copy of either your SF-8 orSF-50 when returning the ES-935.

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Box 7: Complete the DUTY STATION to which you were assigned. Complete the city, county and state. This information

is found on the Form SF-50. Example: If your DUTY STATION was Reno, Nevada but you were assigned to a post in

Doyle, California, list Reno, Washoe, Nevada.

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Box 8: Enter the dates you worked for the agency in the following format: MM-DD-YY to MM-DD-YY. If you worked for

this agency for more than one period during the previous year and a half, enter both periods of employment. Example: 01-

01-01 to 12-01-01

Line(s) 11: Complete this information if you received any Terminal Annual leave at the time you separated from

Civilian Service, including any unused vacation pay or other lump sum terminal leave payments made you. Do

NOT include severance pay. Enter the Gross Amount (before taxes taken) under A, the date you were paid

under B and the number of hours compensated under C. Do NOT complete section D.

Line 13: Write a brief description of why you no longer work for this agency.

SIGN the form in the line provided under Signature of Claimant and Date the form under Date Signed.

Return the form to the address at the bottom of the form. Remember to include COPIES of your SF-8, SF-50

as well as any evidence you may have of your earnings, including paycheck stubs, W2 forms or leave and

earnings statements. Do not send any wage information that is more than a year and a half old.

Example: You filed your claim in June, 2002. Submit wage information for all of 2001, and January

through June 2002.

Remember! Completion of this form does not guarantee you payment of benefits for earnings while a civilian

employee of the Federal Government and that any benefits you MAY be paid as a result of completion of this

form are subject to adjustment and overpayment, for which you may be liable.

Instructions For Es-935 - Claimant'S Affidavit Of Federal Civilian Services, Wages And Reason For Separation