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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the 'PRINT NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON' and their 'ENTER SOCIAL SECURITY NUMBER'. This information is crucial for identifying the individual related to the benefits.
- In section 1(a), provide details about contributors, including their names, addresses, and relationship to the claimant. Specify the contribution periods and amounts. Ensure accuracy as this affects benefit eligibility.
- For section 2, indicate if the claimant had any wages or income. If yes, specify the amount per month and which months this applied to.
- Complete section 3 if applicable, detailing contributions from parents if the claimant is a child living with more than one parent. Include financial agreements if they exist.
- Finally, sign and date the form in the designated area, providing your contact information for follow-up.
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