Form DWS-ARK-501 "Application for Unemployment Insurance Benefits" - Arkansas

What Is Form DWS-ARK-501?

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

Form Details:

  • Released on August 26, 2015;
  • The latest edition provided by the Arkansas Department of Workforce Services;
  • Easy to use and ready to print;
  • Available in Vietnamese;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DWS-ARK-501 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Workforce Services.

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Download Form DWS-ARK-501 "Application for Unemployment Insurance Benefits" - Arkansas

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APPLICATION FOR UNEMPLOYMENT
INSURANCE BENEFITS
CLAIMANT INFORMATION
(*Information Fields Must Be Completed)
TODAY'S DATE:
*
SOCIAL SECURITY NUMBER:
EFFECTIVE DATE: (Local Office Only)
*Have you filed an unemployment claim in another state in the last 12 months? (Other than Arkansas)
Yes
No
*If yes which State?:
*FIRST NAME:
MIDDLE INITIAL
*LAST NAME:
Mailing Address: *ADDRESS - Line 1:
ADDRESS - Line 2:
*ZIP CODE:
*CITY:
*STATE:
Physical Address: (if different than above): ADDRESS - Line 1:
ADDRESS - Line 2:
CITY:
ZIP CODE:
*State of Residence:
*County of Residence:
E-Mail Address:
HOME PHONE:
MOBILE:
MESSAGE ONLY:
*DATE OF BIRTH:
*GENDER:
Male
Female
*YEARS OF EDUCATIION:
ETHNICITY:
Non Hispanic
Hispanic
American Indian
Native Hawaiian
Other (Biracial or
RACE
White
Black
Asian
or Alaska Native
or Pacific Islander
Multiracial)
*Have you worked in another state(s) within the
Yes
No
Yes
No
Are you handicapped (disabled)?
past 18 months?
Yes
No
*Are you a citizen of the United States?
If yes, List States:
If not a citizen, were you legally authorized to work in
Yes
No
the United States during the past 18 months?
If yes, Permit Number:
Have you worked for an Educational Institution within the last 18 month?
Yes
No
If Yes, Were you laid off with reasonable assurance of recall the next semester?
Yes
No
If No, Are you on holiday recess or spring break with reasonable assurance of recall following the holiday or spring break?
Yes
No
LAST EMPLOYER INFORMATION
(Current Employer if working - or - if not working, last employer)
UNIT NUMBER: (Local Office Only)
*EMPLOYER NAME:
ACCOUNT NUMBER: (Local Office Only)
*STREET NAME:
*CITY:
*STATE:
*COUNTY:
*ZIP CODE:
EMPLOYER PHONE:
DATE LAST WORK ENDED:
Are you scheduled to return to work or start a new job within 10 weeks?
Yes
No
If yes date you are scheduled to return to work:
*Was your last work?
1 - Full time (40 hrs)
2-Part time (less than 40 hrs)
3-Temporary (120 days or less)
*Type of separation:
Laid Off:
Quit:
Discharged:
School Employee:
Other:
Sleeping
Weather
Personal Emergency
Spring Break
Suspension
Medical Leave
Lack of Work
Health
Fighting
Summer Break
Shared Work
Strike
Finished Job
General
Absent/Tardy
Holiday
Vacation
Holidays
Business Closed
Insubordination
Lockout
Still Working Part time
Drinking/Drug Test
Family Medical Leave
General
Reduced from full time (40 hrs)
Military
Page 1 of 2
DWS-ARK-501 (Rev. 11-04) v08262015
APPLICATION FOR UNEMPLOYMENT
INSURANCE BENEFITS
CLAIMANT INFORMATION
(*Information Fields Must Be Completed)
TODAY'S DATE:
*
SOCIAL SECURITY NUMBER:
EFFECTIVE DATE: (Local Office Only)
*Have you filed an unemployment claim in another state in the last 12 months? (Other than Arkansas)
Yes
No
*If yes which State?:
*FIRST NAME:
MIDDLE INITIAL
*LAST NAME:
Mailing Address: *ADDRESS - Line 1:
ADDRESS - Line 2:
*ZIP CODE:
*CITY:
*STATE:
Physical Address: (if different than above): ADDRESS - Line 1:
ADDRESS - Line 2:
CITY:
ZIP CODE:
*State of Residence:
*County of Residence:
E-Mail Address:
HOME PHONE:
MOBILE:
MESSAGE ONLY:
*DATE OF BIRTH:
*GENDER:
Male
Female
*YEARS OF EDUCATIION:
ETHNICITY:
Non Hispanic
Hispanic
American Indian
Native Hawaiian
Other (Biracial or
RACE
White
Black
Asian
or Alaska Native
or Pacific Islander
Multiracial)
*Have you worked in another state(s) within the
Yes
No
Yes
No
Are you handicapped (disabled)?
past 18 months?
Yes
No
*Are you a citizen of the United States?
If yes, List States:
If not a citizen, were you legally authorized to work in
Yes
No
the United States during the past 18 months?
If yes, Permit Number:
Have you worked for an Educational Institution within the last 18 month?
Yes
No
If Yes, Were you laid off with reasonable assurance of recall the next semester?
Yes
No
If No, Are you on holiday recess or spring break with reasonable assurance of recall following the holiday or spring break?
Yes
No
LAST EMPLOYER INFORMATION
(Current Employer if working - or - if not working, last employer)
UNIT NUMBER: (Local Office Only)
*EMPLOYER NAME:
ACCOUNT NUMBER: (Local Office Only)
*STREET NAME:
*CITY:
*STATE:
*COUNTY:
*ZIP CODE:
EMPLOYER PHONE:
DATE LAST WORK ENDED:
Are you scheduled to return to work or start a new job within 10 weeks?
Yes
No
If yes date you are scheduled to return to work:
*Was your last work?
1 - Full time (40 hrs)
2-Part time (less than 40 hrs)
3-Temporary (120 days or less)
*Type of separation:
Laid Off:
Quit:
Discharged:
School Employee:
Other:
Sleeping
Weather
Personal Emergency
Spring Break
Suspension
Medical Leave
Lack of Work
Health
Fighting
Summer Break
Shared Work
Strike
Finished Job
General
Absent/Tardy
Holiday
Vacation
Holidays
Business Closed
Insubordination
Lockout
Still Working Part time
Drinking/Drug Test
Family Medical Leave
General
Reduced from full time (40 hrs)
Military
Page 1 of 2
DWS-ARK-501 (Rev. 11-04) v08262015
APPLICATION FOR UNEMPLOYMENT
INSURANCE BENEFITS
*Have you had work of any kind since your LAST EMPLOYER?
Yes
No
*Was your Employer a Temporary Help firm?
Yes
No
*What kind of work did you do on your last job?:
ADDITIONAL EMPLOYER
(*Information Fields Must Be Completed)
UNIT NUMBER: (Local Office Only)
*EMPLOYER NAME:
ACCOUNT NUMBER: (Local Office Only)
*STREET NAME:
*CITY:
*STATE:
*COUNTY:
*ZIP CODE:
EMPLOYER PHONE:
DATE LAST WORK ENDED:
Are you scheduled to return to work or start a new job within 10 weeks?
Yes
No
If yes date you are scheduled to return to work:
*Was your last work?
1 - Full time (40 hrs)
2-Part time (less than 40 hrs)
3-Temporary (120 days or less)
*Type of separation:
Laid Off:
Quit:
Discharged:
School Employee:
Other:
Sleeping
Weather
Personal Emergency
Spring Break
Suspension
Medical Leave
Lack of Work
Health
Fighting
Summer Break
Shared Work
Strike
Finished Job
General
Absent/Tardy
Holiday
Vacation
Holidays
Business Closed
Insubordination
Lockout
Still Working Part time
Drinking/Drug Test
Family Medical Leave
General
Reduced from full time (40 hrs)
ELIGIBILITY INFORMATION
(*Information Fields Must Be Completed))
*Do you want to have Federal Taxes withheld
*Do you have children/others that require care? ..
Yes
No
Yes
No
from your weekly benefit payment? ......
*If Yes, have arrangement for their care
Yes
No
been made if you find work?
*Are you entitled to or are you receiving any of the following:
Have you refused any job since you became
Yes
No
*Vacation Pay? ......
Yes
No
unemployed? .....
Are you attending school?
Yes
No
*Sick Pay? ......
Yes
No
If No, Are you planning on attending school?
Yes
No
Yes
No
*Severance Pay? ......
If Yes, Do you have a date for entering
Yes
No
Yes
No
*Profit Sharing? ......
school in future?
Undecided
Yes
No
*Have you worked in Federal Employment in the past
*Paid off Time? ......
Yes
No
18 months? (Not to include Military Service) .......
*Are you receiving or have you applied for a pension, annuity, or retirement
from former employers? (not including social security)
*If Yes, *1)Do you have a copy of your SF-8
Yes
No
Yes
No
or SF-50? (ES 931 Form) ..........
*2) Do you have proof of your last
Yes
No
*Can you begin work immediately? ......
Yes
No
earnings? (ES 935 Form) ..........
Yes
No
*Can you work Full Time? ......
*Have you had active Military Service in the
Yes
No
past 18 months? ......
*Do you have transportation to a job or has
*If Yes, do you have a copy of your DD-214? ......
Yes
No
Yes
No
transportation to a job been arranged? ......
*If Yes, Form 970 required ......
*If No, MA - 843 required ......
*Do you have any disabilities that limit your ability to
*Do you obtain work through a Union? ......
Yes
No
Yes
No
perform your normal job duties?
*If Yes, Name:
Local Number:
*Are you self-employed, working on a commission or farming which
prevents you from seeking work or accepting a job?
*Are Dues Paid? ...............................
Yes
No
Yes
No
I hereby register for work and file notice of unemployment, and request a determination of my benefit rights under Department of Workforce Services Law. I certify the
information given on this form is correct and understand that penalties are provided for making false statements or failing to disclose material facts in order to obtain
benefits.
Signature:
Date:
LOCAL OFFICE USE ONLY
Yes
No
REQUALIFYING WAGES:
RETURN DATE:
CONTROL DATE:
INTERVIEWERS INITIAL:
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DWS-ARK-501 (Rev. 11-04) v08262015
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