SHARED-WORK PLAN

Biweekly Claim Form-Employer

Opens Shared-Work Plan Biweekly Claim Form-Employer in PDF format
Employer name: Plan number:
Street address:
City: State: ZIP code:
Telephone number: Fax number:
Contact person: Email:
 
Refer to Instructions on Page 2 of this form.
WEEK 1:
/
/
 
 
M M
D D
Y Y Y Y
WEEK 2:
/
/
 
 
M M
D D
Y Y Y Y
 
Please complete this section for employees participating in the Shared-Work Plan. List the number of hours the employee was paid for each claim week. If the employee was paid for time off for any reason, include those hours. Do not include unpaid time off. If you need additional space, please complete additional copies of this form.
 
Social Security No.
Name
Hours Paid
Week 1 Week 2
       
       
       
       
       
       
       
       
       
       
       
       
 
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.
 
 
Employer Signature Date
 
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.
 
 
Title
 
Instructions:
 
To file claims for Shared-Work UC for participating employees, complete this form (in black ink) after the second claim week ends. Once you have signed and dated this claim form, mail it to the office address shown below within seven days of the end of the second week.
 
You will file for two consecutive weeks on this form. A week begins on Sunday and ends on Saturday, regardless of your pay period schedule. Write the week-ending dates of the weeks for which you are filing in the WEEK 1 and WEEK 2 areas on the front of this form.
 
Below are examples showing when to mail the claim form.
 
Filing Two Consecutive Weeks
Week 1 Ending Date
Week 2 Ending Date
Mail The Claim Form
     
2/11/2013
2/18/2013
2/19-2/25/2013
 
Office Address:
 
Office of UC Benefits
ATTN: Shared-Work
651 Boas St., Room 605
Harrisburg, PA 17121
877-785-1531
 
Auxiliary aids and services are available on request to individuals with disabilities.
Equal Opportunity Employer/Program
 
UC-1089 05-13
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