Form UI-17-0299 "Weekly Claim Form" - Washington

What Is Form UI-17-0299?

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

Form Details:

  • Released on April 1, 2017;
  • The latest edition provided by the Washington State Employment Security Department;
  • 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 fillable version of Form UI-17-0299 by clicking the link below or browse more documents and templates provided by the Washington State Employment Security Department.

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Download Form UI-17-0299 "Weekly Claim Form" - Washington

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Weekly Claim Form
Submit this weekly claim form with your job search log.
Claimant name:_____________________________________________Claimant ID:________________________________
The answers to these weekly claim questions apply only from _________________________ to _________________________
MM/DD/YYYY
MM/DD/YYYY
Did you work since you last submitted a weekly claim? ........................................
Yes
No
If yes:
• What is the employer’s name? ___________________________________________________________________
• What is the employer’s address? _________________________________________________________________
• What dates did you work for this employer? From _______________________ to _________________________
MM/DD/YYYY
MM/DD/YYYY
• Why did you separate from this employer? _________________________________________________________
Did you work for more than one employer since you last submitted a weekly claim
Yes
No
?
If yes:
Attach a list of additional employers with their addresses, the dates you worked and why you separated.
1.
Did you or will you receive any of the following from any employer?
• Holiday pay ...........................................................
Yes
No
______Hours ($)________Earnings
• Vacation pay .........................................................
Yes
No
______Hours ($)________Earnings
• Sick pay ................................................................
Yes
No
_ _____Hours ($)________Earnings
• What is the employer’s name? ___________________________________________________________________
• What is the employer’s address? _________________________________________________________________
2.
Have you been or will you be paid for any period after you last worked, such
as severance, termination pay or pay in lieu of notice? .....
Yes
No
If yes:
• Does a contract require your employer
or union to make these payments? ..........................
Yes
No
• Is your employer paying you
throughout a notice period? ...................................
Yes
No
• Has your employer attached any requirements to
the pay? For example, do you need to be available
for work for any time after your last day worked? ......
Yes
No
• Would your employer stop paying you severance if
you got a new job before the payment period ends?
Yes
No
• What is the employer’s name? ___________________________________________________________________
• What is the employer’s address? _________________________________________________________________
• How much are you being paid for the week, before deductions?
______Hours ($)________Earnings
3.
Did you work for any employer(s), whether or not you’ve
been paid yet, since you last submitted a weekly claim?*
Yes
No
______Hours ($)________Earnings
• What is the employer’s name? ___________________________________________________________________
If yes:
• What is the employer’s address? _________________________________________________________________
• Did work for this employer end, even temporarily? ....
Yes
No
Mark the reason:
Fired
Quit
Leave of absence
Suspended
Laid off due to lack of work
If yes:
• On what date did you last work for this employer? _______________
MM/DD/YYYY
* Attach a list of any additional employer(s) for whom you worked, but have not yet been paid. For each employer
listed, include your earnings, the hours you worked, the date you last worked and the reason you separated.
(Page 1 of 2)
Weekly Claim Form
Submit this weekly claim form with your job search log.
Claimant name:_____________________________________________Claimant ID:________________________________
The answers to these weekly claim questions apply only from _________________________ to _________________________
MM/DD/YYYY
MM/DD/YYYY
Did you work since you last submitted a weekly claim? ........................................
Yes
No
If yes:
• What is the employer’s name? ___________________________________________________________________
• What is the employer’s address? _________________________________________________________________
• What dates did you work for this employer? From _______________________ to _________________________
MM/DD/YYYY
MM/DD/YYYY
• Why did you separate from this employer? _________________________________________________________
Did you work for more than one employer since you last submitted a weekly claim
Yes
No
?
If yes:
Attach a list of additional employers with their addresses, the dates you worked and why you separated.
1.
Did you or will you receive any of the following from any employer?
• Holiday pay ...........................................................
Yes
No
______Hours ($)________Earnings
• Vacation pay .........................................................
Yes
No
______Hours ($)________Earnings
• Sick pay ................................................................
Yes
No
_ _____Hours ($)________Earnings
• What is the employer’s name? ___________________________________________________________________
• What is the employer’s address? _________________________________________________________________
2.
Have you been or will you be paid for any period after you last worked, such
as severance, termination pay or pay in lieu of notice? .....
Yes
No
If yes:
• Does a contract require your employer
or union to make these payments? ..........................
Yes
No
• Is your employer paying you
throughout a notice period? ...................................
Yes
No
• Has your employer attached any requirements to
the pay? For example, do you need to be available
for work for any time after your last day worked? ......
Yes
No
• Would your employer stop paying you severance if
you got a new job before the payment period ends?
Yes
No
• What is the employer’s name? ___________________________________________________________________
• What is the employer’s address? _________________________________________________________________
• How much are you being paid for the week, before deductions?
______Hours ($)________Earnings
3.
Did you work for any employer(s), whether or not you’ve
been paid yet, since you last submitted a weekly claim?*
Yes
No
______Hours ($)________Earnings
• What is the employer’s name? ___________________________________________________________________
If yes:
• What is the employer’s address? _________________________________________________________________
• Did work for this employer end, even temporarily? ....
Yes
No
Mark the reason:
Fired
Quit
Leave of absence
Suspended
Laid off due to lack of work
If yes:
• On what date did you last work for this employer? _______________
MM/DD/YYYY
* Attach a list of any additional employer(s) for whom you worked, but have not yet been paid. For each employer
listed, include your earnings, the hours you worked, the date you last worked and the reason you separated.
(Page 1 of 2)
4.
Did you work in casual labor (such as mowing a neighbor’s lawn or helping friends move) or
self-employment, whether or not you have been paid yet? ........
Yes
No
If yes:
• Was this work casual? ......................................................
Yes
No
• Provide your hours worked and net profit,
after business expenses are deducted. ............................... _______Hours ($)_________ Earnings
5.
Have you been or will you be paid for jury duty? .......................
Yes
No ($)_________ Earnings
6.
Did you apply for or receive workers’ compensation? ................
Yes
No
7.
Did you apply for or have a change in a retirement plan not
previously reported? ....................................................................
Yes
No
If yes:
• What is the name of the union or employer
that contributed to this fund?__________________________________________________________________
8.
Are you attending a school or training program? ......................
Yes
No
If yes:
• Has your approved training plan changed? .......................
Yes
No
9.
Were you physically able and available for work
each day of the week? ..............................................................
Yes
No
10.
Did you complete at least three job search activities and keep
a written record as required? .....................................................
Yes
No
If yes:
Complete a job search log and include it with this document.
11.
Did you refuse any offer of work? .............................................
Yes
No
12.
Did you fail to apply for work as specifically
directed by WorkSource? .............................................................
Yes
No
Answer questions 13 –16 only if you are a member of a full referral union.
13.
Are you still a registered member of your union? ......................
Yes
No
14.
If you are in full-time apprenticeship training,
what are your training dates? .................................................. From ______________ to _______________
MM/DD/YYYY
MM/DD/YYYY
15.
Were you eligible for dispatch or referral
as required by your union? ..........................................................
Yes
No
16.
Did you refuse a dispatch or bid for work from your union? ......
Yes
No
Be sure this form and your job search log are complete. We cannot accept weekly claims that are incomplete or unsigned.
I certify that the information I provided on this form is true and complete to the best of my knowledge. I understand that
omitting or giving false information is considered fraud, and I might have to pay back benefits received and pay a penalty.
I also could be denied future unemployment benefits.
MM/DD/YYYY
Signature (required):
Date:
The Employment Security Department is an equal opportunity employer/programs. Auxiliary aids and services are available upon request to individuals
with disabilities. Language assistance services for limited English proficient individuals are available free of charge. Washington Relay Service: 711
(Page 2 of 2)
UI-17-0299 (4/2017)
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