Purpose
To obtain from you information we need to determine the eligibility for unemployment compensation of one of your employees or former employees. (See Form)

Use
The Division of Unemployment Insurance will mail this form to you for completion if:
(a) We have no record of having received from you quarterly wage information for the named claimant on a properly completed Form WR-30, "Employer Report of Wages Paid," OR
(b) Weekly wage information (instead of quarterly wage information) is needed to properly determine the benefit entitlement for the individual listed.

Use by Employer
This form will identify the claimant by name and Social Security number, will show the mailing date, and will specify the period of time for which wage information is needed. You are required by law to complete the form and return it within 10 days of the mailing date to the office shown on the form.

Be sure to sign and date the certification and give the name and telephone number of an individual we can contact if we need more information.