Fillable Ia 12.3 - Record Of Employment (For Unemployed Insurance Purposes Only) printable pdf download

Record of Employment

NYS Department of Labor

IA 12.3 (6-01)

FOR UNEMPLOYMENT INSURANCE PURPOSES ONLY

To Be Filled in By Employee

TO EMPLOYEE:

KEEP THIS CERTIFICATE

Social Security

Account Number

Have it with you if you apply for Unemployment Insurance. This

certificate shows your job was insured. It does not necessarily

Name of

Employee

mean you are qualified to receive benefits. The Claims Center will

make that determination if you apply for benefits.

To Be Filled in By Employer

OPTIONAL IF NEEDED BY EMPLOYER

04 - 51291

N.Y. State Employer Registration Number

TO LOCATE EMPLOYEE RECORD

___________________________________

Payroll or

Federal Employer Identification Number

Clock No.

___________________________________

Location of

Columbia University

Firm Name:

Employment

c/o Corporate Cost Control, Inc.

or Code

P.O. Box 1180

Mailing Address Where

Londonderry, NH 030503

Payroll Records Are Kept:

THIS MAY NOT BE USED AS AN IDENTIFICATION CARD

Date issued to employee:

HOW TO APPLY FOR UNEMPLOYMENT INSURANCE

Unemployment insurance is protection for people who are out of work through no fault of their own. It provides them a

weekly benefit to keep them and their families going while they look for new jobs. If you become unemployed and want

to apply for unemployment insurance benefits, call 1-888-209-8124 (if you live in NY state) or 1-877-358-5306 (for non-NY

state residents). You may also apply online at See a list of offices on page 2 of this form.

Have the following information available when you call:

1. Your Social Security Account Number

2. Your NYS Driver’s License or Motor Vehicle ID card, if you have one

3. Your alien registration card, if you have one

4. Any Record of Employment form or other form given to you by an employer in the past 18 months which

shows:

a. the name of your employer

b. the employer’s NYS Employer Registration Number

c. the mailing address where your employer keeps payroll records

d. your payroll or clock number

e. the address at which you worked

5. Former federal employees should have all federal separation forms and “Notification of Personnel Action”

forms issued in the past 18 months

6. Ex-servicemembers should have Separation Form DD 214 and any DD 215 forms received

FOR COLUMBIA UNIVERSITY USE ONLY

ATTENTION MANAGERS: A copy of this form must be given to all employees, both permanent and

casual, who terminate employment with Columbia University. Please tear off the section below and

forward it to: Human Resources, Studebaker 5th Floor, MC 8710.

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _

I, ___________________________________ (Employee Name), have received the NY State Department of

Labor "Record of Employment Form" on __________________________ (Date).

This form indicates that my job was covered by unemployment insurance. It does not necessarily mean I will

receive benefits. The unemployment office will make that determination if I apply for benefits.

________________________________ _____________________________ __________________________

Employee's Signature

Employee's Social Security No.

Employee's Admin. Department

Ia 12.3 - Record Of Employment (For Unemployed Insurance Purposes Only)

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