Application to Modify Approved Shared-Work Plan

Opens Application to Modify Approved Shared-Work Plan in PDF format
Employer Information
Employer name:
Employer account no.:
Street address:
Zip code:
Telephone number:
FAX number.:
Contact person:
Affected unit:
Plan no..:
The employer requests to modify the approved Shared-Work Plan identified above as follows:
Change the number of weeks the Shared-Work Plan will be in effect from          weeks to          weeks. (The maximum duration of a Shared-Work plan is 52 weeks.).
Change the reduction percentage from        percent to        percent. (The reduction percentage must be no less than 20 percent and no more than 40 percent.)
Add newly anticipated weeks during the effective period of the plan when participating employees' hours of work will be reduced by more than the reduction percentage due to holidays, designated vacation periods, equipment maintenance or other similar circumstances. The applicable dates are:
Add/Remove Employee(s):
(if adding)
Normal Work Hours
(if adding)
Work Hours Under
Shared-Work Plan
(if removing)
Other. Explain:
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
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.
Send completed application to modify the approved Shared-Work plan to the following address:
Office of UC Benefits
ATTN: Shared-Work
651 Boas St., Room 605
Harrisburg, PA 17121
The decision to approve or disapprove modification of an approved Shared-Work Plan is a matter within the department's discretion. If the proposed modifications would cause the plan to violate the requirements of the UC Law, the department will disapprove the proposed modifications.
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
UC-1091 REV 02-14
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