UNEMPLOYMENT COMPENSATION EXTENDED BENEFITS (EB) by nhz10206

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									                                        AGENCY FOR WORKFORCE INNOVATION
                                          UNEMPLOYMENT COMPENSATION
                                                  Extended Benefits Eligibility Review
                                                            P O Box 5270
                                                      Tallahassee Fl 32314-5270
                                                          Fax # 999-999-9999

                             UNEMPLOYMENT COMPENSATION EXTENDED BENEFITS (EB)
                                     ELIGIBILITY REVIEW QUESTIONNAIRE


NAME:                                        SSN: _____-____-NNNN                                           DATE MAILED:

The eligibility review is conducted periodically through your Extended Benefit (EB) claim to ensure continued eligibility for
Unemployment Compensation Extended Benefits. Please complete this form and return the completed form within 10 days to
the address or fax number indicated above. Failure to do so may result in delay or denial of benefits.

1. List the types of work you are seeking and the number of years of experience you have in each:


2. Lowest Wage you are willing to accept $                            per (check one)            Hour            Week            Month      Year
3. What days and hours are you willing to work?
4. How many miles ONE WAY are you willing to commute to work ?
5. How would you get to work? (car, bus, walk etc.)
6. Have you been able and available to work since your EB claim began or you last submitted this form?                                YES     NO
   If NO, please explain:
7. Is there any reason you cannot accept an offer of full-time work?              YES            NO
   If YES, please explain:
8. Do you now attend, or do you plan to attend a school or training program?                 YES                NO
   If YES, Starting when ?       /       /        Type of Training:                              Where?
   Days and hours you attend school or training:
9. Have you started receiving a pension from an employer for whom you have worked?                               YES             NO
   If YES: Monthly amount? $                     Starting when?       /     /      Which employer?
10. Do you have any definite offers of work?         YES       NO     If YES, scheduled start date:                          /      /
   Employer’s name:
11. Have you performed any work, full or part-time (including self-employment), since your EB claim began or you last
   submitted this form?       YES       NO        If YES, provide the information requested below:
   Employer’s Name:                                                               Phone: (              )            -
   Employer Address:
    Date you started work:          /        /         Last date you worked:             /            /
   Reason no longer employed:

The information that I have furnished above is true and correct to the best of my knowledge. If I am successful in finding
work, I will correctly report ALL my gross earnings (before taxes) in the week in which they are EARNED when requesting
benefit checks. If I have any questions regarding the unemployment compensation process, I will contact the Claims
Information phone number at 1-800-204-2418. I understand that the Florida Unemployment Compensation Law imposes
penalties for making false statements to obtain unemployment benefits.

Claimant’s Signature:                                                     Date:              /              /
E-mail address:                                                           Telephone #    (              )                -

AWI-Form UCB231EB (Rev 6/09)



                                                     BARCODE
RETURN TO:

Agency for Workforce Innovation
Unemployment Compensation
Extended Benefits Eligibility Review
P O Box 5270
Tallahassee Fl 32314-5270
Fax #: 999-999-9999



CLAIMANT MAILING ADDRESS

								
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