Deo Form Ucb 231 Euc – Fill Out and Use This PDF

DEPARTMENT OF ECONOMIC OPPORTUNITY

Unemployment Compensation

Claimant Eligibility Review Questionnaire

The eligibility review is being conducted to comply with the requirements of the Middle Class Tax Relief and Job Creation Act of 2012, P.L. 112-96, and to ensure your continued eligibility for emergency unemployment compensation (EUC) benefits. Please answer all questions on this form and bring the completed form when you report for reemployment services.

Failure to do so will result in delay or denial of benefits.

(Print) NAME:	SOCIAL SECURITY NUMBER: XXX - XX -
EMAIL ADDRESS:	TELEPHONE NUMBER: ( )	-	______

1. List the types of work you are seeking and the number of years of experience you have in each type of work:

____________

2.

Lowest wage you are willing to accept: $

_____

per (Circle one): Hour

Week

Month

Year

3.

What days and hours are you willing to work? (Circle the days):

Mon

Tues Wed Thurs Fri Sat

Sun

List the hours that you will work during the days you indicated above:

4.

How many miles ONE WAY are you willing to commute to work?

______________

5.

How will you get to work? (car, bus, walk, etc)

____________

6.

Is there any reason you cannot accept an offer of full-time work? Yes

No

__

If “Yes”, what is the reason?

7.

Have you started receiving a pension from a prior employer since you filed your claim? Yes

No

__

8.

Do you have any definite offer of work? Yes

No

_

If “Yes”, enter your scheduled start date:

/

/

Employer’s name:

______________________________________________

Employer’s Address: (Number and Street)

(City)

(State)

_____________(Zip)

_______

The information that I have furnished above is true and correct to the best of my knowledge. If I am successful in finding work, when claiming benefits I will correctly report my gross earnings (before taxes) during the week in which they are earned. If I have any questions regarding the unemployment compensation process, I will contact the Customer Service Center of the Department of Economic Opportunity at 1-800-204-2418. I understand that the Florida Unemployment Compensation Law imposes penalties for making false statements to obtain unemployment benefits.

Claimant’s Signature:

Date:

*PRIVACY ACT STATEMENT

Information you provide to this Department is voluntary and confidential but is required to process your claim. Pursuant to the Internal Revenue Code of 1986, the Social Security Act, 42 U.S.C. 1320b-7(a)1, and s. 443.091(1)(h), F.S., disclosure of your Social Security number is mandatory. Social Security numbers will be used by the Department to report the benefits you receive to the Internal Revenue Service as potential taxable income. In accordance with the Federal Deficit Reduction Act, an amendment to the Federal Social Security Act, and 5 U.S.C. 552a(o)(1)(D), information you provide is subject to verification through computer matching programs and information about your wages and claim may be provided to other federal, state and local agencies or their contractors for verification of eligibility under other government programs to ensure benefits have been properly paid and for statistical and research purposes.

An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities.

DEO FORM UCB-231 EUC (3/12)