Form ETA-81 "Reemployment Assistance Application for Services" - Florida

What Is Form ETA-81?

This is a legal form that was released by the Florida Department of Economic Opportunity - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2012;
  • The latest edition provided by the Florida Department of Economic Opportunity;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ETA-81 by clicking the link below or browse more documents and templates provided by the Florida Department of Economic Opportunity.

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Download Form ETA-81 "Reemployment Assistance Application for Services" - Florida

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DEPARTMENT OF ECONOMIC OPPORTUNITY
REEMPLOYMENT ASSISTANCE APPLICATION FOR SERVICES
PLEASE PRINT YOUR INFORMATION IN BLUE OR BLACK INK ONLY FOR ALL ITEMS (on both sides of the application) AND SIGN THIS FORM.
Complete a Supplement for other employment you have had during the last 18 months.
1. Name: (First, Middle, Last)
*Social Security Number: (see Privacy Act Statement on back of form)
FOR OFFICE USE ONLY, DO NOT WRITE IN THE GRAY AREA BELOW
1a. Other Names Used During Employment
EFF
M
D
Y
DATE
M
D
Y
Date
FILED
2. Local Mailing Address:
CLAIM
NEW
ADD'L
R/O
T
REQUALIFY
Street Address:
Apt.#
City:
State:
Zip:
Residence County:
STATUS
TYPE:
UC
X
FE
CWC
EB
OTHER
3. Telephone Number:
Alternate phone number:
ISSUE: (check one)
UCB-13
MODS
STDK
METHOD
(
)
or (
)
4. Date of Birth:
5. Sex:
6. Height/Weight
NO
Month
Day
Year
YES - enter flag codes
M
F
/
1.
LOCAL OFFICE
FIPS
RES. COUNTY
WDB
YES
NO
2.
7. (Statistical use only)
Are you of Hispanic descent?
IND
W/S
ERP
MCS
Indicate your primary ethnic affiliation:
3.
White (1)
American Indian or
4.
Black or African American (2)
Alaskan Native (4)
Asian (3)
Hawaiian or Pacific Islander (5)
IB4 STATE/FIPS CODE
Information not available (6)
.
8
Identification (ID):
Driver’s License #:
State of Issuance:
Primary DOT Code:
Mo. Exp.
Secondary DOT Code:
Mo. Exp.
_________________________________
_________________________________
State Identification #:________________
State of Issuance:__________________
Disaster Date:
Announcement
_____________________________________________________________________
Documentation presented:
Disaster #: FL
Other ID #:
Type of ID:
____________________________________________________________________
TYPE:
9. Check the number which corresponds to the highest grade you completed:
1. Did not finish High School - Highest grade completed was:
________________________________________________________
Secondary DOT
1
2
3
4
5
6
7
8
9
10
11
12
Primary DOT Code:
Mo Exp.
Code:
Mo.
Exp.
2. High School Diploma or GED
________________________________________________________
3. AA or Post Secondary Vocational/Technical Certificate of Completion
10. Are you handicapped as defined in Section 504 of the
4. BS/BA
5. MS/MA
6. Doctorate
YES
NO
Rehabilitation Act of 1973?
Definition: A person is handicapped if he or she has a physical or
mental impairment which substantially limits one or more major life
activities; has a record of such impairment; or is regarded as having
such impairment.
NOTE: This information will be used for statistical purposes only; is
requested on a voluntary basis; and will be kept confidential.
YES
NO
11. I am a citizen of the United States.
Alien Reg. #:
YES
NO
If no, I am authorized to work in this country.
Expiration Date:
11a. Citizenship:
US Citizen/Nationalized
Lawfully Admitted Alien/Refugee
11b. If not fluent in English, what language do you prefer to use?
Cuban Entrant
Haitian Entrant
Other
12. I hereby apply for DUA for the period beginning:
Employer ID # ___________________________________________
_____________________________________________________________________
13. TYPE INDUSTRY OF EMPLOYER:
14. Unemployment was a result of this disaster because:
___________________________________________________________________
15. Name of employer at time of disaster:
Employer's Street Address
Dates Worked:
Occupation:
FROM:
TO:
City
County
State
Zip
Mo.
Day
Year
Mo.
Day
Year
Supervisor’s Name:
County in which worked:
Total Gross Earnings
Employer's Telephone Number:
Salary Rate:
Total Gross Earnings since
*
$
Per
Sunday of this week:
$
(
)
(*Hour, Week, Month, Year) Occupation or Title:
Form ETA-81 (Rev. 03/12)
DEPARTMENT OF ECONOMIC OPPORTUNITY
REEMPLOYMENT ASSISTANCE APPLICATION FOR SERVICES
PLEASE PRINT YOUR INFORMATION IN BLUE OR BLACK INK ONLY FOR ALL ITEMS (on both sides of the application) AND SIGN THIS FORM.
Complete a Supplement for other employment you have had during the last 18 months.
1. Name: (First, Middle, Last)
*Social Security Number: (see Privacy Act Statement on back of form)
FOR OFFICE USE ONLY, DO NOT WRITE IN THE GRAY AREA BELOW
1a. Other Names Used During Employment
EFF
M
D
Y
DATE
M
D
Y
Date
FILED
2. Local Mailing Address:
CLAIM
NEW
ADD'L
R/O
T
REQUALIFY
Street Address:
Apt.#
City:
State:
Zip:
Residence County:
STATUS
TYPE:
UC
X
FE
CWC
EB
OTHER
3. Telephone Number:
Alternate phone number:
ISSUE: (check one)
UCB-13
MODS
STDK
METHOD
(
)
or (
)
4. Date of Birth:
5. Sex:
6. Height/Weight
NO
Month
Day
Year
YES - enter flag codes
M
F
/
1.
LOCAL OFFICE
FIPS
RES. COUNTY
WDB
YES
NO
2.
7. (Statistical use only)
Are you of Hispanic descent?
IND
W/S
ERP
MCS
Indicate your primary ethnic affiliation:
3.
White (1)
American Indian or
4.
Black or African American (2)
Alaskan Native (4)
Asian (3)
Hawaiian or Pacific Islander (5)
IB4 STATE/FIPS CODE
Information not available (6)
.
8
Identification (ID):
Driver’s License #:
State of Issuance:
Primary DOT Code:
Mo. Exp.
Secondary DOT Code:
Mo. Exp.
_________________________________
_________________________________
State Identification #:________________
State of Issuance:__________________
Disaster Date:
Announcement
_____________________________________________________________________
Documentation presented:
Disaster #: FL
Other ID #:
Type of ID:
____________________________________________________________________
TYPE:
9. Check the number which corresponds to the highest grade you completed:
1. Did not finish High School - Highest grade completed was:
________________________________________________________
Secondary DOT
1
2
3
4
5
6
7
8
9
10
11
12
Primary DOT Code:
Mo Exp.
Code:
Mo.
Exp.
2. High School Diploma or GED
________________________________________________________
3. AA or Post Secondary Vocational/Technical Certificate of Completion
10. Are you handicapped as defined in Section 504 of the
4. BS/BA
5. MS/MA
6. Doctorate
YES
NO
Rehabilitation Act of 1973?
Definition: A person is handicapped if he or she has a physical or
mental impairment which substantially limits one or more major life
activities; has a record of such impairment; or is regarded as having
such impairment.
NOTE: This information will be used for statistical purposes only; is
requested on a voluntary basis; and will be kept confidential.
YES
NO
11. I am a citizen of the United States.
Alien Reg. #:
YES
NO
If no, I am authorized to work in this country.
Expiration Date:
11a. Citizenship:
US Citizen/Nationalized
Lawfully Admitted Alien/Refugee
11b. If not fluent in English, what language do you prefer to use?
Cuban Entrant
Haitian Entrant
Other
12. I hereby apply for DUA for the period beginning:
Employer ID # ___________________________________________
_____________________________________________________________________
13. TYPE INDUSTRY OF EMPLOYER:
14. Unemployment was a result of this disaster because:
___________________________________________________________________
15. Name of employer at time of disaster:
Employer's Street Address
Dates Worked:
Occupation:
FROM:
TO:
City
County
State
Zip
Mo.
Day
Year
Mo.
Day
Year
Supervisor’s Name:
County in which worked:
Total Gross Earnings
Employer's Telephone Number:
Salary Rate:
Total Gross Earnings since
*
$
Per
Sunday of this week:
$
(
)
(*Hour, Week, Month, Year) Occupation or Title:
Form ETA-81 (Rev. 03/12)
DEPARTMENT OF ECONOMIC OPPORTUNITY
REEMPLOYMENT ASSISTANCE APPLICATION FOR SERVICES
Reason for Separation:
Permanent Lay-off
Suspension
Temporary Lay-off
Leave of Absence
Tools/Equipment Used:
Quit or Voluntary Lay-off
Discharged, Job Performance
Working Reduced Hours
Discharged, Other
Are you scheduled to return to work for this employer?
YES
Explain Reason for Separation:
When?
NO
YES
NO
16. Are you currently employed, self-employed or have you been self-employed in the past year?
YES
NO
17. Is there any reason you cannot seek or accept full-time employment?
17
YES
NO
A. Have you refused any offer of work since you became unemployed?
18. Did you apply for or receive, or would you be eligible to receive if applied for: (Mark "Y" for Yes or "N" for No next to each question)
Any amount for loss of wages due to illness or disability?
Any amount of retirement pension or annuity income?
Any type of private income protection insurance?
Worker's compensation for death of head of household?
Any amount as supplemental unemployment benefit?
___________________________________________________________
19. Have you received, or will you receive any of the following payments?
Severance Pay
YES
NO
Amount: $
Wages in Lieu of Notice
YES
NO
Vacation Pay
YES
NO
From:
To:
20. Do you have specific plans to enroll in or attend school or vocational training within the next 12
months?
YES
NO
If yes, when?
(date)
21. Are you receiving, or will you receive a retirement pension?
YES
NO
If yes, date payment began/will begin:
Employer's Name:
22. During the past 18 months, have you:
a. Been in the Military Service?
YES
NO
b. Held a Federal Civilian Job?
YES
NO
c. Worked in any other state?
YES
NO
YES
NO
23. Have you applied for Reemployment Assistance benefits in the past 12 months?
If yes, against which state?
24. If you receive, or will receive payments from Worker's Compensation, is it classified as:
Temporary Total
YES
NO
Temporary Partial
YES
NO
Impairment Income
YES
NO
Permanent Total
YES
NO
Supplemental Income
YES
NO
25. Are you a member of a labor union which finds/obtains work for its members?
YES
NO
If yes, provide Union name and number:
26. What type of work are you seeking?
YES
NO
27. Are you a veteran who meets one or more of the following conditions?
a. Served on active duty for a period of more than 180 days and received a discharge other than dishonorable.
b. Was a reservist who earned a campaign badge and was released or discharged with a discharge other than dishonorable?
c. Was discharged or released from active duty because of a service-connected disability?
If you answered yes to Question 25 above, please answer questions 26 – 30 below, otherwise go to question 31.
28. Were you released from military active duty within the last three years (36 months)?
YES
NO
29. Did you serve on active duty during a war, campaign or expedition for which a campaign badge has been authorized?
YES
NO
YES
NO
30. Are you a Disabled Veteran?
Definition: You have a service-connected disability which entitles you to compensation or caused you to be discharged or released from active duty.
YES
NO
31. Are you a Special Disabled Veteran?
Definition: You are entitled to compensation for a service-connected disability rated at 30 percent or more or 10 or 20 percent with a determination
that you have a serious employment handicap or you were discharged or released from active duty because of service-connected disability.
32. Are you a homeless veteran?
YES
NO
33. Are you the spouse of any of the following individuals?
YES
NO
(a) a veteran who died of a service connected disability; (b) a veteran who has a total service-connected disability; (c) a member of the Armed Forces
serving on active duty who has been listed for a total of more than 90 days in one of the following categories: (I) missing in action; (II) captured in line
of duty by a hostile force; or (III) forcibly detained in the line of duty by a foreign government?
34. If you answered ‘Yes’ to Question 25 or 31 above, you qualify for Special Job Service Veteran’s Assistance through the local One Stop Center
in your area and, unless told otherwise at the time you complete this application, you should report to that office to register for Veteran’s assistance.
Form ETA-81 (Rev. 03/12)
DEPARTMENT OF ECONOMIC OPPORTUNITY
REEMPLOYMENT ASSISTANCE APPLICATION FOR SERVICES
I hereby claim benefits under the Florida Reemployment Assistance Law. I am not seeking benefits under any other state or Federal system. At the
discretion of the department, this application for benefits may be accepted as my registration for work and employment services. I understand the Florida
Reemployment Assistance Law provides penalties for knowingly making false statements for the purpose of obtaining benefits. I declare that the statements
made in connection with this claim are true and correct to the best of my knowledge and belief. I understand the information is subject to verification and
agree to provide such documentation as required.
Claimant Signature:
Date:
The Department of Economic Opportunity may e-mail me for additional information needed in determining my claim.
My E-Mail Address is:__________________________________________________
I understand the Department of Economic Opportunity will maintain the confidentiality of my e-mail address pursuant to section 443.1715, Florida Statutes.
*PRIVACY ACT STATEMENT
Information you provide to this department is voluntary and confidential but is required to process your claim. Pursuant to the Internal Revenue Code of
1986, the Social Security Act, 42 U.S.C. 1320b-7(a)1, and s. 443.091(1)(h), F.S., disclosure of your Social Security number is mandatory. Social Security
numbers will be used by the department to report the benefits you receive to the Internal Revenue Service as potential taxable income. In accordance with
the Federal Deficit Reduction Act, an amendment to the Federal Social Security Act, and 5 U.S.C. 552a(o)(1)(D), information you provide is subject to
verification through computer matching programs and information about your wages and claim may be provided to other federal, state and local agencies or
their contractors for verification of eligibility under other government programs to ensure benefits have been properly paid and for statistical and research
purposes.
An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities.
Form ETA-81 (Rev. 03/12)
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