Form ETA-935 at a glance
What it is: ETA-935 is the Claimant's Affidavit of Federal Civilian Service, Wages and Reason for Separation.
Who signs: The claimant signs in box 10, Signature of Claimant.
A filled-in Form ETA-935 example: a former federal employee reports wages and separation
How to fill out Form ETA-935, box by box
State agency, claimant and claim dates
Enter the State Agency Address in box 1 and the Claimant's Name and Mailing Address in box 2.
Enter the Local Office/ Call Center ID in box 3, the Date of Request in box 4, the Effective Date of Claim in box 5 and the Separation Date in box 6.
Federal agency and Social Security Number
Enter the Federal Agency Name and Address in box 7 and the Social Security Number in box 8.
Official Duty Station and wages
In box 9, the Affidavit of Federal Wage and Separation Information/ Documentary Evidence, enter the location of your Official Duty Station (City, State).
Enter your wages with the above named employer in box 9. Show wages by quarter starting with the wages that you earned after (base period begin date) up to the date you separated from this employer, under Quarter Ending, Year and Gross Wages in box 9. Under Documentary Evidence, enter the source of the information provided and attach a copy. If additional space is needed to explain reason for separation, attach your signed explanation.
Severance Pay and Pension
Severance Pay. Did you receive or are you entitled to receive severance pay provided by Federal law or agency employee agreement? Mark Yes or No. If Yes, complete the following information: Total Entitlement and the Severance Pay Period Begin date and Ending Date.
Pension: Are you entitled to receive a pension from any branch of the Federal Government? Mark Yes or No. Enter Gross Monthly Pension.
Reason for Separation
Enter the Reason for Separation.
Signature of Claimant
Penalties are provided by law for an individual making false statements to obtain benefits, and determinations based on an affidavit are not final: determinations are subject to correction upon receipt of wage and separation information from the Federal agency, and any amount overpaid will have to be repaid or offset against future benefits.
Sign as the claimant in box 10, Signature of Claimant, and enter the Date.
More rules for Form ETA-935
Complete and Return Immediately.
Sources
[1] Form ETA-935, Claimant's Affidavit of Federal Civilian Service, Wages and Reason for Separation, U.S. Department of Labor (the Official source link on this page).