Claimant Certification - Please Read Carefully
I hereby file a claim for unemployment insurance benefits. I certify that the information for my benefit claim, including the status of my
dependents, is true and correct to the best of my knowledge and belief. I am aware that the law prescribes penalties of fine and imprisonment
for making false statements to obtain benefits, including dependent allowance. I understand that the information submitted by me may be
verified through computer matching programs and will be used by other Federal, State, or Local Agencies and that information submitted by me
to these agencies will be used by IDES in determining my eligibility and amount of unemployment benefits. I also understand that, pursuant to
Section 1900 of the Unemployment Insurance Act, any information that I provide to the Department of Employment Security in connection with
the claim may be shared with my former employers or their representatives.
I understand that, unless I am exempt, registration for work with the Illinois Employment Service is a requirement to be eligible for
Unemployment Insurance Benefits under Section 500A of the Illinois Unemployment Insurance Act; unemployment insurance benefits will not be
paid until I complete my registration; and registration can be completed by visiting www.IllinoisJobLink.com.
*CLAIMANT SIGNATURE: *DATE:
Employment History List where you have worked during the past 18 months. (Start with your most recent job.)
If you worked for a Temporary Agency, provide the name, address, and phone # of the Agency.
If you need to list more employers, request the Work History Form.
Employer Name:
*Employer Name:
*Address:
*Why are you no longer working for this employer? (check one)
If you worked for a Temporary Agency provide the name of the employer you worked for or were assigned to.
If you have other employers in the past 18 months, list below. If none, skip to Claimant Certication.
*What was your most recent job title:
*City: *State: *Zip
*Company Phone #: ( )
-
*For this period of employment, what date did you start?
*Last date worked:
/ /
/ /
*In what state(s) was your work performed?
/ / /
Total # of days worked:
Quit
Strike / Lockout / Labor Dispute (Ask for LD Questionnaire)
Laid-Off (Lack of Work)
Still Working (Part Time)
Discharged (Fired)
Military Discharge
*Employer Name:
Employer Name:
*Address:
*Why are you no longer working for this employer? (check one)
If you worked for a Temporary Agency provide the name of the employer you worked for or were assigned to.
*City: *State: *Zip
*Company Phone #: ( )
-
*In what state(s) was your work performed?
/ / /
Total # of days worked:
Laid-Off (Lack of Work)
Quit
Strike / Lockout / Labor Dispute (Ask for LD Questionnaire)
Still Working (Part Time)
Discharged (Fired)
Military Discharge
/ /
CLI001F
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(Ofce Use Only) UI Acct#:
(Ofce Use Only) UI Acct#:
LEU
LEU
LAG
LAG
BCE
BCE
*How many weeks OWBA:
*How many weeks OWBA:
*For this period of employment, what date did you start?
*Last date worked:
/ /
/ /
ID or SSN:
Last Name:
Other Last Name worked under _________________________________
Typically, how many days in a week did you work for this employer ? _______
Typically, how many days in a week did you work for this employer ? _______
Other Last Name worked under ________________________