"Partials Employee Consent Form" - Alabama

Partials Employee Consent Form is a legal document that was released by the Alabama Department of Labor - a government authority operating within Alabama.

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Download "Partials Employee Consent Form" - Alabama

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PARTIALS EMPLOYEE CONSENT FORM
WARNING: Committing an act of unemployment fraud may result in loss of current and future benefits, penalties,
fines and imprisonment.
EMPLOYEE NAME______________________________________________(print)
EMPLOYEE SOCIAL SECURITY NUMBER_____________________________
I authorize my employer, _________________________________________________________,
to file weekly claims for benefits (Partials) for me in the event that the business is closed temporarily. By authorizing
my employer to file these claims, I allow him/her to report the following information on my behalf:
Citizenship status - for employees who are not citizens, the employer will provide a copy of your
employment authorization card to the Payment Processing Unit. Fax number (334)956-7483.
Federal Tax Withholding preference - you may choose to have Federal Tax withheld (at the rate of 10%)
from your Unemployment Compensation benefits. This form allows you to authorize the employer to
report your choice: _______Yes _______ No.
Statistical information - race, sex, disability status, highest grade completed.
Amount of pay received from the employer - the employer will report any pay you are owed
for the week being claimed.
Amount of pay received from outside sources (the employer will report any pay you received
from other employment or other sources.) You must let the employer know if you have pay from
an outside source for the week being claimed. If the pay is not reported by the employer, notify
the Payment Processing Unit at (334)956-7481.
I understand that I must provide my employer with my current address. If my address changes, it is my responsibility
to notify my employer immediately. I understand that, if I provide an incorrect address, the Postal Service will not
forward my AL Vantage Debit Card. I understand that if I feel an error has been made in the information provided, I
should notify the Payment Processing Unit immediately.
I also understand that I will receive a Monetary Determination in the mail when I file a new claim that shows my
base period wages. If wages are missing from this report, I must notify the Payment Processing Unit immediately.
(Wages with the Federal Government, Military or employers outside of Alabama will not be included on the report.
Please notify the Payment Processing Unit if you have any of these types of wages.)
EXCLUSIONS: Employees who receive a pension, worker’s compensation payments, or are in school are required to
inform the employer that a partial claim should not be filed for them. The employer should request and file paper
Ben-3 forms which will be required to be submitted to the Payment Processing Unit.
I understand all of the information above and agree to the terms. I understand that this form must be completed and
returned to the Payment Processing Unit prior to a Partial claim being filed.
SIGNATURE _______________________________________________________
DATE OF CONSENT _________________________________________________
ALABAMA DEPARTMENT OF LABOR
649 MONROE STREET
PARTIAL PAYMENT PROCESSING UNIT
MONTGOMERY, AL 36131
334 956-7481
PARTIALS EMPLOYEE CONSENT FORM
WARNING: Committing an act of unemployment fraud may result in loss of current and future benefits, penalties,
fines and imprisonment.
EMPLOYEE NAME______________________________________________(print)
EMPLOYEE SOCIAL SECURITY NUMBER_____________________________
I authorize my employer, _________________________________________________________,
to file weekly claims for benefits (Partials) for me in the event that the business is closed temporarily. By authorizing
my employer to file these claims, I allow him/her to report the following information on my behalf:
Citizenship status - for employees who are not citizens, the employer will provide a copy of your
employment authorization card to the Payment Processing Unit. Fax number (334)956-7483.
Federal Tax Withholding preference - you may choose to have Federal Tax withheld (at the rate of 10%)
from your Unemployment Compensation benefits. This form allows you to authorize the employer to
report your choice: _______Yes _______ No.
Statistical information - race, sex, disability status, highest grade completed.
Amount of pay received from the employer - the employer will report any pay you are owed
for the week being claimed.
Amount of pay received from outside sources (the employer will report any pay you received
from other employment or other sources.) You must let the employer know if you have pay from
an outside source for the week being claimed. If the pay is not reported by the employer, notify
the Payment Processing Unit at (334)956-7481.
I understand that I must provide my employer with my current address. If my address changes, it is my responsibility
to notify my employer immediately. I understand that, if I provide an incorrect address, the Postal Service will not
forward my AL Vantage Debit Card. I understand that if I feel an error has been made in the information provided, I
should notify the Payment Processing Unit immediately.
I also understand that I will receive a Monetary Determination in the mail when I file a new claim that shows my
base period wages. If wages are missing from this report, I must notify the Payment Processing Unit immediately.
(Wages with the Federal Government, Military or employers outside of Alabama will not be included on the report.
Please notify the Payment Processing Unit if you have any of these types of wages.)
EXCLUSIONS: Employees who receive a pension, worker’s compensation payments, or are in school are required to
inform the employer that a partial claim should not be filed for them. The employer should request and file paper
Ben-3 forms which will be required to be submitted to the Payment Processing Unit.
I understand all of the information above and agree to the terms. I understand that this form must be completed and
returned to the Payment Processing Unit prior to a Partial claim being filed.
SIGNATURE _______________________________________________________
DATE OF CONSENT _________________________________________________
ALABAMA DEPARTMENT OF LABOR
649 MONROE STREET
PARTIAL PAYMENT PROCESSING UNIT
MONTGOMERY, AL 36131
334 956-7481