Purpose
To  verify that the claimant's dependents were unemployed during the calendar week in which the claim became effective. (See Form)

Use
A claimant who did not earn sufficient wages in his/her base-year to receive the maximum weekly benefit rate payable may be entitled to collect dependency benefits provided that, if the claimant is legally married, the claimant's spouse is unemployed during the calendar week in which the claim is effective. Children listed as dependents by the claimant must also be unemployed during the week in which the claim takes effect.

This form is mailed to you because you reported wages on Form WR-30, "Employer Report of Wages Paid," for an individual who is listed as a dependent by the claimant named on the form. The form lists the dependent's name and Social Security number, the quarter for which wages were reported, and the calendar week for which wage information is requested.

Use by Employer
You are required to complete and return this form only if the employee or former employee earned wages during the calendar week specified. If so, complete Items 1 through 4 and return the form to the address listed in the lower left corner of the form. Do  not return the form if the individual did not earn wages during the calendar week specified.