Record of Job Applications and Work Search Activities
You may use this form each week to record your job applications and work search activities. Enter your name and Social Security Number on each sheet and provide the information requested. (See your UCP-1 booklet for information on the work search requirements.) Include additional information or additional pages if needed. Copies of this form are available for download at
www.uc.pa.gov.
If you do not use this form, your work search record must contain all of the information that would be included on this form. Failure to keep a thorough and accurate work search record or failure to provide your record to the department upon request could result in liability to repay benefits you received.
Please note: Do not return your work search record to the department unless specifically requested.
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Name: |
Social Security Number: |
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Week beginning Sunday : |
through Saturday : |
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Job Applications & Work Search Activity |
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Part 1 - Job Applications |
Date |
Employer |
Employer Contact Name and Phone Number |
How Did You Apply For Work? |
Results |
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Part 2 - Work Search Activity |
Date(s) |
Description of Work Search Activity |
PA CareerLink® Contact Name, if applicable |
PA CareerLink® Location, if applicable |
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Exemption Information |
Type of Exemption
(Provide detail) |
Contact Name and Phone Number for Verification (If applicable) |
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Name: |
Social Security Number: |
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Week beginning Sunday : |
through Saturday : |
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Job Applications & Work Search Activity |
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Part 1 - Job Applications |
Date |
Employer |
Employer Contact Name and Phone Number |
How Did You Apply For Work? |
Results |
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Part 2 - Work Search Activity |
Date(s) |
Description of Work Search Activity |
PA CareerLink® Contact Name, if applicable |
PA CareerLink® Location, if applicable |
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Exemption Information |
Type of Exemption
(Provide detail) |
Contact Name and Phone Number for Verification (If applicable) |
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I certify that all information I have provided in this document is correct and complete. I acknowledge that false statements in this document are punishable pursuant to 18 Pa. C.S. §4904, relating to unsworn falsification to authorities.
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First Name |
Last Name |
(print)
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Signature |
Date
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A person who knowingly makes a false statement or knowingly withholds information to obtain UC benefits commits a criminal offense under section 801 of the UC Law, 43 P.S. §871, and may be subject to a fine, imprisonment, restitution and loss of future benefits.
Remember! If you are working full-time, you are not eligible for benefits for that week. If you are working part-time, you must report all work performed and gross wages earned during weeks claimed. Payments will be matched against wages reported by employers to the Department of Labor & Industry.
Auxiliary aids and services are available on request to individuals with disabilities.
Equal Opportunity Employer/Program
UC-304 03-12
