Indiana Job Attachment Form Details

The State Form 54244 is a document used to report the actions of an uncooperative taxpayer. This form can be used to report taxpayers who are not following the tax laws, or who are refusing to cooperate with the state or federal government in regards to their taxes. By using this form, you can help protect your rights and ensure that the taxpayer is held accountable for their actions.

Below are some facts you may want to review before starting working with the state form 54244.

QuestionAnswer
Form NameState Form 54244
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesunemployment protest form, form 54244, indiana form 54244, 54244 640p

Form Preview Example

UNEMPLOYMENT INSURANCE PROTEST (EMPLOYER)

State Form 54244 (R/8-11), DWD 640P

INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT

CONFIDENTIAL RECORD PURSUANT TO IC 22-4-19-6, IC 4-1-6

*This agency is requesting the disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.

Claimant Name

 

 

 

Social Security Number

Benefit Year End

 

 

 

 

 

Claimant Street Address, City, State and ZIP Code

 

 

 

 

 

 

 

 

 

 

Employer

 

 

 

Indiana SUTA (Employer Account Number)

 

 

 

 

 

 

Employer Address, City, State and ZIP Code

 

 

 

 

Employee worked from:

______/______/______

to last day worked:

______/______/______

 

mm/dd/yyyy

Reason for Protest (Check all that apply)

Quit - (Code 10)

mm/dd/yyyy

School Worker - (Code 20)

(this could include job abandonment, stopped showing up, retired, employee personal reasons, no contact to check on further assignments, etc.)

(Check this box if the employer is a school and has offered the claimant reasonable assurance to return to work after the most recent customary recess).

Discharge for Cause - (Code 20)

(this could include terminations for absenteeism or attendance, sleeping on the job, documented poor performance, policy violations, etc).

Employment Status - (Code 70)

(this would include situations where the claimant never worked for the employer, is still employed in the same job under generally the same terms, or otherwise not unemployed by the employer or a planned plant shut down).

Gross Misconduct - (Code 30)

Work Refusal, Failed Drug Test - (Code 70)

(this is defined by Ind. Code 22-4-15-6.1 and would include an employee committing a crime that would be considered a Felony or Class A Misdemeanor, being intoxicated, committing battery, fraud, or other situations involving theft or embezzlement).

Did the claimant receive income upon separation or thereafter?

Vacation

 

Severance

 

Sick

 

Personal

(Check this box if the individual refused an offer of work, or if the individual refused to take or failed a pre-employment drug test).

Pension/401k

 

Other

Please note: You will receive additional requests from the UI Adjudication Center seeking specific details concerning the employee's separation. Please respond

to these requests as quickly as possible. Failure to respond to requests from the department can result in a penalty, even if the employee is later determined ineligible.

Brief Statement of Facts regarding separation:

Employer Contact Name

 

 

Date

 

 

 

 

 

 

mm/dd/yyyy

 

Employer Signature

 

 

Phone (

)

 

 

 

 

 

 

area code

 

Check here if you are attaching additional supporting documents to this fax, total number of additional pages:

Fax Form to: UI Adjudications 317-633-7206

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