Form Teuc202a - Temporary Extended Unemployment Compensation
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1
2Temporary Extended
Rev. 03/2002
Unemployment Compensation
Montana Department of Labor & Industry
Helena Phone Center (406) 444-2545
Unemployment Insurance Division
Billings Phone Center (406) 247-1000
PO Box 8020
TDD (406) 444-0532
Helena, Montana 59604-8020
Fax: (406) 444-2699
SSN:
Date Mailed:
1. Is the mailing address shown above correct?
Yes
No
If “No,” please provide correct mailing address:
2. Phone Number: Home: (
)
Message: (
)
Cell: (
)
3. Do you wish to have federal income tax withheld at a rate of 10%?
Yes
No
4. Citizen: Yes
No
Alien Registration Expiration Date:
If “No,” Alien Registration Number
5. Have you had any of the following in the last 18 months?:
If “Yes,” go to #12.
Full Time Military Employment?
Yes
No
If “Yes,” do you have a copy of DD214 Member 4?
Yes
No
If “Yes,” Please provide a copy.
Federal Civilian Employment?
Yes
No
If “Yes’” enter employer information in #12.
Employment in any state(s) other than Montana?
Yes
No
If “Yes,” enter employer information in #12.
Filed an Unemployment Insurance Claim in any other state
or Canada?
Yes
No
If “Yes,” name of state:
Date Filed:
Filed for a paid Workers’ Compensation Claim?
Yes
No
If “Yes,” give date of injury:
6. Are you currently:
Attending school or planning to attend school
Yes
No
If “Yes,” give start date:
Able and available for full time work?
Yes
No
If “No,” please explain:
Self-employed/running your own business?
Yes
No
If “Yes,” please explain:
7. Are you a member of a union with a hiring hall?
Yes
No
If “Yes,” Local Number:
Name:
Phone Number (
)
8. Will you be returning to, or starting employment with any employer(s), 30 hours per week or more?
Yes
No
If “Yes,” Name:
Phone Number: (
)
Start Date:
9. List your last employer.
Reason for Separation:
Lack of Work
Quit
Fired
Strike/Lockout
(Business Name)
Last Employer Name
(Explain)
Still Working
Medical
Leave of Absence
Mailing Address
Phone: (
)
If this is Federal (UCFE) Employment:
Fax: (
)
(a) Position Title:
City, State, Zip
(b) Part Time/Seasonal:
Yes
No
(Starting and End Dates)
Last Employed
(Duty Sta ion, City, Sta e)
t
t
(c) Place of Employment:
Start:
End:
Page 1 of 2
03/15/2002 Form:TEUC202A
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Parent category: Legal