Augusta, ME 04332-0349 Telephone: (207) 512-3100 Toll-free: 1-800-451-9800 Fax: (207) 512-3285 TTY: -2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the month for which you are reporting in the designated field labeled 'FOR THE MONTH OF:'.
3. Fill in your name and Social Security number in the 'Recipient Name' and 'Social Security #' fields respectively. Ensure accuracy as this information is crucial.
4. Provide your home phone number and mailing address in the respective fields to ensure proper communication.
5. In the 'EMPLOYMENT CONTACTS' section, list each company you contacted, including their name, address, contact person, method of contact (letter, phone, or in person), and any comments regarding your interaction.
6. Answer all certification questions at the bottom of the form. If you answer 'YES' to any question, provide additional details as required.
7. Sign and date the form at the bottom to certify that all information provided is true and correct before submitting it.

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