Application for Unemployment Compensation Benefits (Claimant)

Opens Application for Shared-Work Plan (Claimant) in PDF format
Complete ALL questions on this form. If your answer is "NONE," please write "NONE."

PART A: Claimant Information

Social Security Number:
First Name: MI:
Last Name:
Other Last Name (if used within the last two years):
Mailing Address
City, State, Zip:
Residence Address (if different)
City, State, Zip:
Home Telephone Number:
Home Fax Number:
County of Residence:
Township or Borough of Residence:
Home Email Address (optional):
PA Driver's License (optional):
Birth Date:
Gender: Female Male
Highest Grade Completed:
Are you a citizen of the United States?
Yes No
If No, Alien Registration Number:
Do you consider yourself to have a disability?
Yes No
Choose not to answer
Of the following categories, how do you describe yourself?
Not Hispanic or Latino
Hispanic or Latino
Ethnicity Unknown
Out of the following categories, how do you describe yourself?
White Multiple Races
Black Asian
American Indian/Alaskan Native
Hawaiian/Pacific Islander
Information Not Available
Please Note: UC benefits are subject to federal income tax. You may elect to have federal income tax withheld from your UC benefits. The amount of federal income tax withheld per week is 10 percent of your gross weekly benefit rate (the amount of UC you would receive if you were totally unemployed before deductions, if any), not the amount of Shared-Work UC you actually receive. For example, if your weekly benefit rate is $200 and you are in a Shared-Work Plan with a 20 percent reduction to your work hours, your weekly Shared-Work UC amount would be $40 (20 percent of $200). If you elect to have federal tax withheld, you would receive $20 and $20 would go to the Internal Revenue Service (10 percent of $200 is $20).
Do you want 10 percent of your gross weekly benefit rate withheld for federal income tax?
Yes No

PART B: Employer Information

Employer Name:
Address: City, State, Zip:
First Day Worked: Reason for leaving: Shared-Work Plan (Lack of Work)
Last Day Worked:
Did you earn $3,384 or more from this employer during your most recent period of employment?
Yes No
If employed less than one year for this employer, how long did you work for your previous employer?
Are you working full or part time for any other employer, including the Reserves or National Guard?
Yes No
In the past two years, have you:
Served on active duty in the U.S. Military?
  Yes No
Worked for an employer in a state other than Pennsylvania?
  Yes No
(Note: Out-of-state military service is not considered out-of-state employment.)
If Yes, in which state(s) were you employed?
Worked as a civilian for the federal government?
  Yes No
Worked for a college, university or school?
  Yes No
Worked for any local or state government?
  Yes No
In the next year, will you receive a pension (excluding Social Security or railroad retirement) or lump sum payment from an employer you worked for during the past 18 months?
  Yes No
Are you or will you receive a severance payment or payments (excluding pensions, retirement payments, accrued leave payments and supplemental unemployment benefits) from any employer?
  Yes No
Are there any conditions under which you may not be able and available to work during the next year?
  Yes No
Have you received or been approved for workers' compensation within the last 18 months?
  Yes No
Do you get your jobs through a union hiring hall?
  Yes No
Are you engaged in self-employment, working on a commission basis, or operating a farm?
  Yes No
  If Yes to self-employed, please select the situation which most closely resembles your self-employment activity:
  Sideline Business Independent Contractor Business Owner
Are you the child, parent or spouse of your last employer?
  Yes No
  If Yes to child, are you under the age of eighteen (18)?
  Yes No
Did you serve as an officer for the company where you were last employed?
  Yes No
  If Yes, did you own stock? Yes No
If you live outside Pennsylvania, did you cross the Pennsylvania state line to commute to work?
  Yes No
In the past 18 months, have you worked in Pennsylvania?
  Yes No
Did you serve over 180 days on active duty for the U.S. Military?
  Yes No
If Yes, have you ever been classified as a disabled veteran?
  Yes No
  If Yes, percent of disability is percent
The UC program provides an additional allowance of $5 per week for one dependent or $8 for two or more dependents, up to a maximum of 26 weeks. A dependent is a legally-married spouse, child under the age of 18, or a child unable to accept gainful employment due to physical or mental infirmity.
Do you have dependents?
Yes No
If Yes, are you the main support of the dependents you are claiming?
Yes No
  If Yes, how many dependents do you wish to claim?
Are you claiming your spouse as a dependent?
Yes No
  If Yes, spouse's first name:
Dependent child(ren)'s name(s):
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.
First Name Last Name (print)
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.
NOTE: For weeks when the Shared-Work Plan is in effect, the employer will file claims for shared work UC on your behalf and on behalf of the other participating employees. However, there may be certain circumstances where your eligibility for UC will be determined under the regular UC eligibility criteria. If any of these circumstances arise you will be instructed to file a claim on your own behalf and a claim form will be sent to you. If you have any questions concerning the application process, please call 877-785-1531.
Auxiliary ads and services available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
UC-1088 02-12
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