Envelope Securityiwork in shipping and receiving all for truck pick up

Location:

Posted:

March 14, 2023

Resume:

In order to receive the weekly unemployment benefits due to you from the New York State Department of Labor, complete and sign this secure form.

Dear Claimant:

This form displays certain week(s) that you may be eligible to receive unemployment benefits. Please select ‘I was eligible’ or ‘I was not eligible’ for each week displayed below. For each selection, you hereby certify that the statements herein are true and correct and understand that they may be used in a hearing involving your claim. In addition, you are certifying that you have complied with any work search in the week(s) that is claimed and that you are not claiming benefits for any period during which you were outside of the United States, a U.S. Territory or Canada. You further acknowledge that you understand that the law provides penalties for false statements. The information on this form is secure. WHAT YOU NEED TO DO:

1. Review the requirements to confirm your eligibility 2. Select ‘I was eligible’ or ‘I was not eligible’ for each week displayed below 3. Sign this secure form and input your social security number 4. Click the “Finish” button to submit

By checking the box indicating ‘I was eligible’ next to the following week(s), you are certifying that:

I did not work any day, including self-employment;

I did not earn more than $504, excluding self-employment;

I did not refuse any job offer or job referral;

I was not owed, and did not receive, vacation pay or holiday pay;

I was ready, willing, and able to work; and

I did not return to work.

If you cannot certify to these requirements, you should check the box indicating ‘I was not eligible’ next to that week. I was eligible I was not eligible

Week ending

DocuSign Envelope ID: 89D03991-D8DF-4033-AC09-1DA6F87C97DD 07/05/2020

06/14/2020

07/26/2020

08/02/2020

05/31/2020

requirements

05/03/2020

07/12/2020

You hereby certify that the statements herein are true and correct and understand that they may be used in a hearing involving your claim. You may be required to provide documentation to the Department of Labor regarding the above. If you provide inaccurate information that results in an improper overpayment of benefits, you may be subject to penalties in addition to repayment of such overpayments. Signature:

Name:

Date Signed:

Social Security Number:

DocuSign Envelope ID: 89D03991-D8DF-4033-AC09-1DA6F87C97DD LAURA KING

9/22/2020

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