Package Handler United States
Resume:
AFFIDAVIT
CLAIMANTS STATEMENT OF WAGES EARNED
I, SS# being duly sworn, depose and say that I worked for _ in the City or Town of in the State Of Connecticut from
to, and earned as wages the following amounts:
Calendar Quarter
Beginning
Ending
Dollar Amount
First
January 1, 2023
March 31, 2023
$
Second
April 1, 2023
June 30, 2023
$
Third
July 1, 2023
September 30, 2023
$
Fourth
October 1, 2023
December 31, 2023
$
Total (usually equal to form W2 issued by your employer)
$
Calendar Quarter
Beginning
Ending
Dollar Amount
First
January 1, 2022
March 31, 2022
$
Second
April 1, 2022
June 30, 2022
$
Third
July 1, 2022
September 30, 2022
$
Fourth
October 1, 2022
December 31, 2022
$
Total (usually equal to form W2 issued by your employer)
$
Calendar Quarter
Beginning
Ending
Dollar Amount
First
January 1, 2021
March 31, 2021
$
Second
April 1, 2021
June 30, 2021
$
Third
July 1, 2021
September 30, 2021
$
Fourth
October 1, 2021
December 31, 2021
$
Total (usually equal to form W2 issued by your employer)
$
My weekly gross cash wages were $__0.00 . In addition, I received $ 0.00 meals a day and $ 0.00 in tips weekly.
This affidavit is made for the purpose of establishing unemployment benefit rights under Chapter 567 of the 1958 supplement to the Connecticut General Statutes, and I am aware that Section 31-273(a) provides as follows:
“Any person who shall knowingly make a false statement or representation or fail to disclose a material fact in order to obtain, increase, prevent or decrease any benefit, contribution or other payments under this chapter, or under any similar law of another state or of the United States in regard to which this state acted as agent pursuant to an agreement or authorized by section 31-255, whether to be made to or by himself or any other person, shall be fined not more than two hundred dollars or imprisoned not more than six months or both.”.
Dated at this day of, 20__ Sworn to and subscribed before me.
Claimant’s Signature Notary Public
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