Customer Service Income Tax
Resume:
DIRECTOR
LISA GREENE
INKSTER MI 48141-2820
UIA 1713 C/E
(Rev. 02-21)
GRETCHEN WHITMER
GOVERNOR
STATE OF MICHIGAN
DEPARTMENT OF LABOR AND ECONOMIC OPPORTUNITY
UNEMPLOYMENT INSURANCE AGENCY
Authorized By
MCL 421.1 et seq.
SUSAN R. CORBIN l
Mail Date:
Letter ID:
March 7, 2024
L0140475599
CB6205790
LISA GREENE
CLM:
Name:
Request for Information
A question of eligibility and/or qualification has been raised on a claim in which you are an interested party. Respond to the questions on the reverse side of this form and keep a copy for your records. Return the completed form to Unemployment Insurance (UI) by March 18, 2024. Failure to respond to this request for information will result in a determination based on available information. U S PARK
9420
December 31, 2023 Case Number: 46232496
Employer Name:
Social Security Number:
Benefit Year Begin:
How to Respond
Submit copies (not the originals) of any records which you believe support your position, such as pay stubs, layoff slip, federal income tax form, W-2, etc. If you require additional space, attach additional pages(s). Include your name, Claim ID and Letter ID as shown above, on all documents that you submit. You can respond online, by mail or fax. To submit your response through your MiWAM account, go to www.michigan.gov/uia and select "Additional fact finding is required for your claim." If you do not have an existing MiWAM account, you can create an account by selecting "Register as a New User", and follow the prompts. To respond by mail, return the completed form along with a copy of any additional documents to Unemployment Insurance Agency, P.O. Box 169, Grand Rapids, MI 49501-0169 or fax to 517-***-****. Penalties
It is against state law to intentionally make false statements or conceal material information to gain or avoid the payment of benefits. You may have to repay up to 1.5 times the amount of benefits received. Benefits will be stopped, and any remaining benefits will be lost. You may also be subject to criminal prosecution. If prosecuted, you may be required to pay court costs and fines, face jail time, perform community service or any combination of these.
If your address changes it is important to update it with Unemployment Insurance. If you have questions, contact UIA Customer Service at 1-866-***-****. TTY customers use 1-866-***-****. EAN: 113****-***
l
1 UIA is an Equal Opportunity Employer/Program.
Auxiliary aids, services and other reasonable
accommodations are available upon request to
individuals with disabilities.
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UIA 1713 C/E Letter ID: L0140475599
(Rev. 02-21)
Additional information is necessary regarding Personal Reasons. False
What was your last day worked?
Did you give notice to the employer that you were leaving? Yes No
What date did you tell the employer would be your last day of work?
What was the personal reason you voluntarily quit work? Attending School/Training
Child Care
Loss of Transportation
Other Personal Reasons
Relocation
Relocation of Military Spouse
Request for Leave Denied
Was your military spouse reassigned to a new geographic location? Yes No
Did you relocate to the new location with your military spouse? If yes, submit documentation which verifies relocation with spouse.
Yes No
Certification: I certify that the information I have reported is true and correct. I understand that if I intentionally make a false statement, misrepresent facts or conceal material information to reduce or prevent benefits, I may be required to repay benefits, charged damages and could be subject to criminal prosecution. Signature Date Telephone Number
Print Name Title
UIA is an Equal Opportunity Employer/Program.
Auxiliary aids, services and other reasonable
accommodations are available upon request to
l individuals with disabilities.
1
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UIA 1713 C/E Letter ID: L0140475599
(Rev. 02-21)
l
1 UIA is an Equal Opportunity Employer/Program.
Auxiliary aids, services and other reasonable
accommodations are available upon request to
individuals with disabilities.
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UIA 1713 C/E Letter ID: L0140475599
(Rev. 02-21)
English
IMPORTANT! This document(s) contains important information about your unemployment compensation rights, responsibilities and/or benefits. It is critical that you understand the information in this document. IMMEDIATELY: If needed, call 1-866-***-**** for assistance in the translation and understanding of the information in the document(s) you have received.
Spanish
IMPORTANTE! Este documento (s) contiene información importante sobre sus derechos, responsabilidades y / o beneficios de compensación de desempleo. Es fundamental que comprenda la información de este documento. INMEDIATAMENTE: Si es necesario, llame al 1-866-***-**** para obtener ayuda en la traducción y comprensión de la información en el (los) documento (s) que ha recibido. Arabic
Albanian
• E RËNDËSISHME! Ky dokument përmban informacione të rëndësishme për të drejtat, përgjegjësitë dhe / ose përfitimet e kompensimit të papunësisë. Është e rëndësishme që ju të kuptoni informacionin në këtë dokument.
• MENJËHERË: Nëse është e nevojshme, telefononi 1-866-***-**** për ndihmë në përkthimin dhe kuptimin e informacionit në dokumentet që keni marrë.
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