Catalog#+: 08 I95
/ Y e a r
0 I. White, Not Hispanic
0 2. Black, Not Hispanic
0 3. Hispanic
0 4.A merican Indian/Alaskan Native
0 5.Asian or Pacific Islander
0 6. Information Not Available
only one-half of any monthly Social Security received.)
13. IS THIS WORKER A CORPORATE OFFICIAL
0 N O
0 YES a
0 YES 0
(/frJO, complete Number 17.)
UCB-I 14...Revised 12/97
SOUTH CAROLINA EMPLOYMENT SECURITY COMMISSION
LOW EARNINGS AND PARTIAL CLAIM REPORT
THIS IS TO CERTIFY THAT THIS WORKER WAS EMPLOYED DUklNd CLAIM WEEK ENDING...
2. WORKER’ S NAME
6. SOCIAL SECURITY NUMBER
NAME WORKED UNDER (ifdifferent)
17. CLAIM WEEK ENDING DATE
3. MAILING ADDRESS
5. COUNTY of RESIDENCE (see reverse side fir name and code)
9. EMPLOYER ACCOUNT NUMBER
I I. TOTAL OF
12. TOTAL MONTHLY PENSION AMOUNT RECEIVED.
14. IS THIS WORKER THE CHILD (less than 18 years old),
SPOUSE, OR PARENT OF EMPLOYER?
OF THIS BUSINESS?
TO BE COMPLETED BY WORKER
HAS YOUR ADDRESS CHANGED SINCE YOU LAST FILED FOR UNEMPLOYMENT INSURANCE BENEFITS?
is important thut you veriQ your od?lress in 3,4. and 5.)
I CERTIFY UNDER PENALM OF PERJURY THAT I AM A CITIZEN OR NATIONAL OFTHE UNITED,STATES.
I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT I AM IN A SATISFACTORY IMMIGRATION STATUS.
18. WORKER’ S TELEPHONE NUMBERz
ITEM I I ABOVE MUST SHOW TOTAL EARNINGS. FROM THIS EMPLOYER AS WELL AS ANY OTHER EMPLOYER.
WORKER’ S CERTIFICATION: I certify that I was able to work and available for work during the week claimed. I certify that the answers on this form are
true and correct to the best of my knowledge. I understand that the law provides penalties for making false statements to obtain or increase benefits.
EMPLOYER’ S CERTIFICATION: I certify that for the period covered by this claim, the worker was employed and accepted all available work
EMPLOYER’ S SIGNATURE
WORKER’ S SIGNATURE
DATE OF PREPARATION
RETURN ORIGINAL FORM ONLY
THIS FORM WILL BE MACHINE READ.........DO NOT FOLD OR BEND