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) Yes No *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: Male Female

*YEARS OF EDUCATION:

*ETHNICITY:

1-White-Non Hispanic 2-Black-Non Hispanic 3-Hispanic

(RACE) 4-American Indian or American Native 5-Asian Pacific Islander 6-Other

Are you handicapped (disabled)? Yes No

*Are you a citizen of the United States?

Yes No

If not a citizen, were you legally authorized to work in

the United States during the past 18 months?

Yes No

If yes, Permit Number:

* Have you worked in another state(s) within the

past 18 months?

Yes No

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?

Yes No

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:

Weather Personal Emergency Sleeping Spring Break Suspension Medical Leave

Lack Of Work Health Fighting Summer Break Shared Work Strike

Finished Job General Absent/Tardy Holiday Vacation Holidays

Business Closed Insubordination Lockout Still Working Part time

Drinking/Drug Test Family Medical Leave

General Reduced from full time (40 hrs)

Have you worked for an Educational Institution within the last 18 months? Yes No

If Yes, Were you laid off with reasonable assurance of recall the next semester?

Yes No

If No, Are you on a holiday recess or spring break with reasonable assurance of recall following the holiday or spring break?

Yes No

How did you get your last job?

1-Employment Security 2-In Person 3-Correspondence 4-Phone

5-Union 6-Other 7-Temporary Agency

What kind of work did you do on your last job?:

What was your rate of pay on your last job? $ Per

Hour Day Week Semi-Monthly Monthly

What hours did you work? From: AM PM To: AM PM

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?

Yes No

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:

Weather Personal Emergency Sleeping Spring Break Suspension Medical Leave

Lack Of Work Health Fighting Summer Break Shared Work Strike

Finished Job General Absent/Tardy Holiday Vacation Holidays

Business Closed Insubordination Lockout Still Working Part time

Drinking/Drug Test Family Medical Leave

General Reduced 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?.. Yes No

from your weekly benefit payment?...... Yes No *If Yes, have arrangement for their care

*Have you had work of any kind since your been made if you find work?

Yes No

LAST EMPLOYER?..... Yes No Have you refused any job since you became

*Are you entitled to or are you receiving any of the following: unemployed?..... Yes No

*Vacation Pay?...... Yes No Are you attending school? Yes No

*Holiday Pay?...... Yes No If No, Are you planning on attending school? Yes No

*Bonus Pay?......

Yes No If Yes, Do you have a date for entering Yes No

*Sick Pay?...... Yes No school in future? Undecided

*Severance Pay?...... Yes No *Have you worked in Federal Employment in the past

*Profit Sharing?......

Yes No 18 months?(Not to include Military Service)........ Yes No

*Paid off Time...... Yes No *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)........... Yes No

from former employers? (not including social security) Yes No *2)Do you have proof of your last

*Can you begin work immediately?...... Yes No earnings?(ES 935 Form).... Yes No

*Can you work Full Time?......

Yes No *Have you had active Military Service in the

*Do you have transportation to a job or has past 18 months? ...... Yes No

transportation to a job been arranged?......

Yes No *If Yes, do you have a copy of your DD-214? ...... Yes No

*Do you have any disabilities that limit your ability to *If Yes, Form 970 required. ......

perform your normal job duties? Yes No *If No, MA - 843 required. ......

*Are you self-employed, working on a commission or farming which *Do you obtain work through a Union? ...... Yes No

prevents you from seeking work or accepting a job? Yes No *If Yes, Name:

Local Number:

*Are Dues Paid?........................

Yes No

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: Yes No

RETURN DATE: CONTROL DATE: INTERVIEWERS INITIALS:

DWS-ARK-501 Page 2 of 2 (Rev. 11-04)