WEEKLY CLAIM FORM FOR UNEMPLOYMENT INSURANCE DESK CERTIFICATION C.C. No. _________________ BYE ______________ NAME:_____________________________________________ look for work, or refused a job during this week, do not mail this form. Take it to the career center where you filed your COMPLETE THE FOLLOWING FOR THE WEEK THAT BEGAN _________________ AND ENDED_______________. claim. Yes No Did you work or earn wages? If yes, give employer's name ________________________________ and total amount earned ______________________________ (Caution: Wages must be reported when they are earned, not when they are paid.) Yes No Are you still working? If no, check reason below: Job Ended Other Social Security Number WED If you were not available for work, not able to work, did not Read this statement before signing and dating: I certify that during this week I was able, available and actively seeking work and did not refuse any work offered. All information I have shown on this form is true to the best of my knowledge and belief. I understand the law provides penalties for making false statements on this form. Claimant's Signature Date DOL-421 (R-11/02) WEEKLY CLAIM FORM FOR UNEMPLOYMENT INSURANCE DESK CERTIFICATION C.C. No. _________________ BYE ______________ NAME:_____________________________________________ COMPLETE THE FOLLOWING FOR THE WEEK THAT BEGAN _________________ AND ENDED_______________. Yes No Did you work or earn wages? If yes, give employer's name ________________________________ and total amount earned ______________________________ (Caution: Wages must be reported when they are earned, not when they are paid.) Yes No Are you still working? If no, check reason below: Job Ended Other Social Security Number WED If you were not available for work, not able to work, did not look for work, or refused a job during this week, do not mail this form. Take it to the career center where you filed your claim. Read this statement before signing and dating: I certify that during this week I was able, available and actively seeking work and did not refuse any work offered. All information I have shown on this form is true to the best of my knowledge and belief. I understand the law provides penalties for making false statements on this form. Claimant's Signature Date DOL-421 (R-11/02) WEEKLY CLAIM FORM FOR UNEMPLOYMENT INSURANCE DESK CERTIFICATION C.C. No. _________________ BYE ______________ NAME:_____________________________________________ look for work, or refused a job during this week, do not mail this form. Take it to the career center where you filed your COMPLETE THE FOLLOWING FOR THE WEEK THAT BEGAN _________________ AND ENDED_______________. claim. Yes No Did you work or earn wages? If yes, give employer's name ________________________________ and total amount earned ______________________________ (Caution: Wages must be reported when they are earned, not when they are paid.) Yes No Are you still working? If no, check reason below: Job Ended Other Social Security Number WED If you were not available for work, not able to work, did not Read this statement before signing and dating: I certify that during this week I was able, available and actively seeking work and did not refuse any work offered. All information I have shown on this form is true to the best of my knowledge and belief. I understand the law provides penalties for making false statements on this form. Claimant's Signature American LegalNet, Inc. www.FormsWorkFlow.com Date DOL-421 (R-11/02)