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Click ‘Get Form’ to open it in the editor.
Begin by entering your name and Social Security Number (SSN) at the top of the form. If applicable, include your previous name if it has changed.
In the 'Waiting Week' section, specify the Sunday week ending date for which you are claiming benefits.
Complete Part A – Employee Statement by answering all questions regarding your work status during the claimed week. Be sure to indicate if you worked for anyone other than your Shared Work employer.
If you answered 'Yes' to working elsewhere, provide details on how many days you worked and your earnings. Also, confirm whether you are still employed with your Shared Work employer.
Sign and date the certification statement at the bottom of Part A, ensuring all information is accurate before submission.
Return the completed form to your employer for them to fill out Part B and submit it to the Department of Labor.

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Versions	Form popularity	Fillable & printable
2017	4.1 Satisfied (33 Votes)
2013	4 Satisfied (24 Votes)

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