"Dislocated Worker Benefits Training Verification" - Maine

Dislocated Worker Benefits Training Verification is a legal document that was released by the Maine Department of Labor - a government authority operating within Maine.

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MAINE DEPARTMENT OF LABOR
Bureau of Unemployment Compensation
DISLOCATED WORKER BENEFITS TRAINING VERIFICATION
Dated:___________________________
CLAIMANT DETAILS
Claimant Name: _____________________________________
Last 4 of Claimant SSN: ___________________
Benefit Year: ____________________________
VERIFICATION OF TRAINING ATTENDANCE FOR THE WEEK ENDING SATURDAY_______________________
DISLOCATED WORKER BENEFITS (DWB) TRAINING VERIFICATION
1. Were you able to attend, and did you attend, all scheduled approved training during the week claimed?
YES____
NO____
A. If “NO,” give the date(s) and reason(s) for absence in the Remarks Section below.
2. How many days during the week are you scheduled for training?________________________________________
3. Are you on school vacation or a break in training?
YES____
NO____
A. If “Yes,” give start and end dates of break in training.
From___________
To___________
4. If the training has been completed or terminated, give the last date of attendance:_____________________
Remarks:
Claimant Certification: I certify that all statements for the week covered are true and correct. I know the law imposes
penalties for false statements made on this claim. I am not seeking any other State, Railroad, or Federal unemployment
insurance.
Claimant’s Signature
Date
Training Facility or Training Sponsor Certification: The answers in questions 1, 2, 3, and 4 are in accordance with our
records. Statements made by the claimant appear to be complete and correct to the best of my knowledge, unless
otherwise noted.
Facility/Sponsor Name:
Telephone No:
Signature
Date
Please mail or fax this form to the Unemployment Claim Center listed below:
Maine Department of Labor
Bureau of Unemployment Compensation
97 State House Station
Augusta, ME 04333-0097
Fax No. (207) 287-5905
MAINE DEPARTMENT OF LABOR
Bureau of Unemployment Compensation
DISLOCATED WORKER BENEFITS TRAINING VERIFICATION
Dated:___________________________
CLAIMANT DETAILS
Claimant Name: _____________________________________
Last 4 of Claimant SSN: ___________________
Benefit Year: ____________________________
VERIFICATION OF TRAINING ATTENDANCE FOR THE WEEK ENDING SATURDAY_______________________
DISLOCATED WORKER BENEFITS (DWB) TRAINING VERIFICATION
1. Were you able to attend, and did you attend, all scheduled approved training during the week claimed?
YES____
NO____
A. If “NO,” give the date(s) and reason(s) for absence in the Remarks Section below.
2. How many days during the week are you scheduled for training?________________________________________
3. Are you on school vacation or a break in training?
YES____
NO____
A. If “Yes,” give start and end dates of break in training.
From___________
To___________
4. If the training has been completed or terminated, give the last date of attendance:_____________________
Remarks:
Claimant Certification: I certify that all statements for the week covered are true and correct. I know the law imposes
penalties for false statements made on this claim. I am not seeking any other State, Railroad, or Federal unemployment
insurance.
Claimant’s Signature
Date
Training Facility or Training Sponsor Certification: The answers in questions 1, 2, 3, and 4 are in accordance with our
records. Statements made by the claimant appear to be complete and correct to the best of my knowledge, unless
otherwise noted.
Facility/Sponsor Name:
Telephone No:
Signature
Date
Please mail or fax this form to the Unemployment Claim Center listed below:
Maine Department of Labor
Bureau of Unemployment Compensation
97 State House Station
Augusta, ME 04333-0097
Fax No. (207) 287-5905