Fillable Printable De 1545 Page--04-09-12
Fillable Printable De 1545 Page--04-09-12
De 1545 Page--04-09-12
SAMPLE
DE 1545
NOTICE OF WAGES USED FOR UNEMPLOYMENT INSURANCE (UI) CLAIM
DE 1545 Rev. 55 (8-11) (INTERNET) Page1of2 CU
CLAIMANT’S NAME
NAME WAGES REPORTED UNDER SOCIAL SECURITY NUMBER OTHER SOCIAL SECURITY NUMBER
*I F INFORMATION ABOUT WAGES IS CORRECT AND YOU DO NOT WISH TO REQUEST A RULING, NO FURTHER
ACTION IS NECESSARY. THIS FORM IS FOR YOUR RECORDS.
THE PERSON NAMED BELOW HAS RECEIVED UI BENEFITS BASED IN TOTAL OR IN PART ON WAGES YOU REPORTED.
WAGES YOU REPORTED BY QUARTER USED TO ESTABLISH THIS CLAIM (BASED ON )
FO
R INFORMATION REGARDING BASE PERIOD, SEE ENCLOSED INSTRUCTIONS
TOTAL WAGES
REPORTED BY YOU
TOTAL WAGES REPORTED BY YOU AND ALL OTHER EMPL OYERS TO ESTABLISH THIS CLAIM .....................
THE PERCENTAGE OF BENEFITS CHARGEABLE TO YOUR RESERVE ACCOUNT IS .........................................
THE CLAIMANT’S WEEKLY BENEFIT AMOUNT IS TO A MAXIMUM BENEFIT AMOUNT OF ....................
RULINGS: To request a ruling, supply the information below and mail to the address in the upper left corner.
1. Give date(s) of separation(s) and rehire(s) (if any) during quarters used to establish this claim.
Separation(s) Dates(s)
Rehire(s) Date(s)
2. Did the claimant notify you that he/she quit? Yes No
3. Give complete details about separation
The above statements were taken from business records or are based on knowledge of the undersigned.
PRINT NAME
DATE
SIGNATURE/TITLE PHONE NUMBER ( )
YOUR ACCOUNT NO. BR. NO.
PREDECESSOR ACCOUNT NO .
CLAIM DATE
*RULING REQUESTS MUST BE POSTMARKED BY
SAMPLE
FOR DEPARTMENT USE ONLY
DATE SSN
DOCUMENTS MADE PART OF RECORD CLAIMANT NAME
ER PROTESTED DATE TIMELY UNTIMELY DE 3977 DE 4463 DE 4464 DE 4465
Reason for Favorable Ruling
Employer Statement
BDG Reason for Decision
Part-Time
Favorable
Unfavorable
Accepts other Employment
Rate of Pay
Employers Name
Address
Department Representative (Print Name)
FOR DEPARTMENT USE ONLY
Claimant Statement
DE 1545 Rev. 55 (8-11) (INTERNET) Page2of2
