Fillable Printable Unemployment Insurance Form - Arkansas
Fillable Printable Unemployment Insurance Form - Arkansas
Unemployment Insurance Form - Arkansas
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APPLICATION FOR UNEMPLOYMENT
INSURANCE BENEFITS
STATE OF ARKANSAS
DEPARTMENT OF WORKFORCE SERVICES
CLAIMANT INFORMATION
(*Information Fields Must Be Completed)
TODAY'S DATE:*SOCIAL SECURITY NUMBER:EFFECTIVE DATE: (Local Office Only)
*Have you filed an unemployment claim in another state in the last 12 months? (Other than Arkansas)YesNo*If yes which State?:
*FIRST NAME:MIDDLE INITIAL:*LAST NAME:
Mailing Address: *ADDRESS - Line 1:ADDRESS - Line 2:
*CITY:*State:*Zip:
Physical Address (if different than above): ADDRESS - Line 1:ADDRESS - Line 2:
CITY:Zip:
*State of Residence:*County of Residence:E-Mail Addr:
HOME PHONE:()
MOBILE:()
MESSAGE ONLY:()
*DATE OF BIRTH:
*GENDER:MaleFemale
*YEARS OF EDUCATION:
*ETHNICITY:
1-White-Non Hispanic2-Black-Non Hispanic3-Hispanic
(RACE)4-American Indian or American Native5-Asian Pacific Islander6-Other
Are you handicapped (disabled)?YesNo
*Are you a citizen of the United States?
YesNo
If not a citizen, were you legally authorized to work in
the United States during the past 18 months?
YesNo
If yes, Permit Number:
* Have you worked in another state(s) within the
past 18 months?
YesNo
If yes, List States:
LAST EMPLOYER INFORMATION (Current Employer if working - or - if not working, last employer)
*EMPLOYER NAME:ACCOUNT NUMBER:
(Local Office Only)UNIT NUMBER: (Local Office Only)
*STREET NAME:
*CITY:*STATE:*COUNTY:*ZIP CODE:
EMPLOYER PHONE:()ORIGINAL HIRE DATE:DATE LAST WORK ENDED:
Are you scheduled to return to work or start a new job within 10 weeks?
YesNo
If yes date you are scheduled to return to work:
*Was your last work?
1-Full time (40 hrs)2-Part time (less than 40 hrs)3-Temporary (120 days or less)
*Type of separation:
Laid Off:Quit:Discharged:School Employee:Other:
WeatherPersonal EmergencySleepingSpring BreakSuspensionMedical Leave
Lack Of WorkHealthFightingSummer BreakShared WorkStrike
Finished JobGeneralAbsent/TardyHolidayVacationHolidays
Business ClosedInsubordinationLockoutStill Working Part time
Drinking/Drug TestFamily Medical Leave
GeneralReduced from full time (40 hrs)
Have you worked for an Educational Institution within the last 18 months?YesNo
If Yes, Were you laid off with reasonable assurance of recall the next semester?
YesNo
If No, Are you on a holiday recess or spring break with reasonable assurance of recall following the holiday or spring break?
YesNo
How did you get your last job?
1-Employment Security2-In Person3-Correspondence4-Phone
5-Union6-Other7-Temporary Agency
What kind of work did you do on your last job?:
What was your rate of pay on your last job?$Per
HourDayWeekSemi-MonthlyMonthly
What hours did you work?From:AMPMTo:AMPM
DWS-ARK-501 Page 1 of 2 (Rev. 11-04)CONTINUE ON REVERSE SIDE
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ADDITIONAL EMPLOYER (*Information Fields Must Be Completed)
*EMPLOYER NAME:ACCOUNT NUMBER: (Local Office Only)UNIT NUMBER: (Local Office Only)
*STREET NAME:
*CITY:*STATE:*COUNTY:*ZIP CODE:
EMPLOYER PHONE:()ORIGINAL HIRE DATE:DATE LAST WORK ENDED:
Are you scheduled to return to work or start a new job with 10 weeks?
YesNo
If yes date you are scheduled to return to work
*Was your last work?
1-Full time (40 hrs)2-Part time (less than 40 hrs)3-Temporary (120 days or less)
*Type of separation:
Laid Off:Quit:Discharged:School Employee:Other:
WeatherPersonal EmergencySleepingSpring BreakSuspensionMedical Leave
Lack Of WorkHealthFightingSummer BreakShared WorkStrike
Finished JobGeneralAbsent/TardyHolidayVacationHolidays
Business ClosedInsubordinationLockoutStill Working Part time
Drinking/Drug TestFamily Medical Leave
GeneralReduced from full time (40 hrs)
ELIGIBILITY INFORMATION(*Information Fields Must Be Completed)
*Do you want to have Federal Income Taxes withheld*Do you have children/others that require care?..YesNo
from your weekly benefit payment?......YesNo *If Yes, have arrangement for their care
*Have you had work of any kind since your been made if you find work?
YesNo
LAST EMPLOYER?.....YesNo Have you refused any job since you became
*Are you entitled to or are you receiving any of the following: unemployed?.....YesNo
*Vacation Pay?......YesNo Are you attending school?YesNo
*Holiday Pay?......YesNo If No, Are you planning on attending school?YesNo
*Bonus Pay?......
YesNo If Yes, Do you have a date for enteringYesNo
*Sick Pay?......YesNo school in future?Undecided
*Severance Pay?......YesNo*Have you worked in Federal Employment in the past
*Profit Sharing?......
YesNo 18 months?(Not to include Military Service)........YesNo
*Paid off Time......YesNo *If Yes *1)Do you have a copy of your SF-8
*Are you receiving or have you applied for a pension, annuity, or retirement or SF-50? (ES 931 Form)...........YesNo
from former employers? (not including social security)YesNo *2)Do you have proof of your last
*Can you begin work immediately?......YesNo earnings?(ES 935 Form)....YesNo
*Can you work Full Time?......
YesNo*Have you had active Military Service in the
*Do you have transportation to a job or has past 18 months? ......YesNo
transportation to a job been arranged?......
YesNo *If Yes, do you have a copy of your DD-214? ......YesNo
*Do you have any disabilities that limit your ability to *If Yes, Form 970 required. ......
perform your normal job duties?YesNo *If No, MA - 843 required. ......
*Are you self-employed, working on a commission or farming which*Do you obtain work through a Union? ......YesNo
prevents you from seeking work or accepting a job?YesNo *If Yes, Name:
Local Number:
*Are Dues Paid?........................
YesNo
I hereby register for work and file notice of unemployment, and request a determination of my benefit rights under Arkansas Department of Workforce
Services Law. I certify the information given on this form is correct and understand that penalties are provided for making false statements or failing to
disclose material facts in order to obtain benefits.
Signature:Date:
LOCAL OFFICE USE ONLY
REQUALIFYING WAGES:YesNo
RETURN DATE:CONTROL DATE:INTERVIEWERS INITIALS:
DWS-ARK-501 Page 2 of 2 (Rev. 11-04)
