APPLICATION FOR UNEMPLOYMENT INSURANCE BENEFITS

Marshallese

DWS-ARK-501 v01182020 Page of

LE KO KAKE EO EJ KOMMAN AN CLAIM (*aolep field nan uak rej aikuij kanne)

*TODAY'S DATE: *SOCIAL SECURITY NUMBER: EFFECTIVE DATE: (Local Office Only)

Em j ke am kadedelok im jakemanlok juon am claim kon an jako am jjerbal (unemployment claim) ioi bar juon state ilo 12 allon ko remotlok? (Other than Arkansas)

Aet Jab *If yes, which State?

*ETAM: LETA JINOIN ET EO IOLAP: * ETAN BAAMLE EO:

Mailing Address: * ATREEJ - Line 1: ATREEJ- Line 2:

*CITY: *STATE: *ZIP:

Physical Address (If different than above): ATREEJ - Line 1: ATREEJ- Line 2:

CITY: STATE: ZIP:

* State eo kwoj pad ie: * County eo kwoj pad ie: E-Mail Address:

PHONE EO NMWEO: MOBILE: JEJE ENNAAN WOT (MESSAGE):

* RAAN IN LOTAK: * KAIN ROT (SEX): * IIO KO IN JIKUUL:Ladik Ledik

Ew r ke jorren ilo anbwinin (jaje makitkit)? Aet Jab * Kwoj ke juon citizen in United States? Aet JabElaññe ejab kwe juon citizen, ew r ke am maron, ekkar nan kakien, in jerbal iilo United ASttes ilo 18 allon ko remotlok?

Aet Jab

Elaññe aet, je number melim eo:

* Em j ke am kar jerbal ilo bar juon state(s) ilowan 18 alon ko remotlok? Aet Jab

Elaññe aet, kolajraki State ko:

LAST EMPLOYER INFORMATION (Armij eo ej kojrbal eok elaññe kwoj jerbal wot - oak - elaññe kwoj jab, etanarmij e oak buainess ear kojerbal eok aliktata)

Kwoj ke bojak nan jikinjerbal ak jino juon jerbal kaal ilowan wot 10 wiik ko? Aet Jab

If yes, date you are scheduled to return to work:

* Jikin jerbal aliktata? 1-Likieo in awa in jerbal (40 hrs) 2-Part time (Edik jan 40 awa)

* ARMIJEO EAR KOJERBALE EOK: ACCOUNT N MBA (Local Office Only) N MBA IN UNIT: (Local Office Only)

* ETAN STREET:

* CITY: *STATE: *COUNTY: *ZIP CODE:

ARMIJ ROT (ETHNICITY): (RACE)

Riamerican Indian ak Rialaska Native

Mool in Rihawaii Armij in Pacific

Bar Jet (Biracial or Multiracial)Ribelle (White) Rikilmeej (Black) Riasia

Ejap Rihispan Rihispan

Em jke am erbal nan juon jikin jelalokijen ko ilowan kar 18 allon ko? Aet JabElaññe Aet, rarkabwijrak eok jan jerbal, ew r kar lomnak bwe kwon naj bar rol semester in tok? Aet Jab

Elaññe Jab, kwoj ke pad ilo am kakkije ke bwaj iien kakije kio, ejemlok jikuul kin melele in renaj kir eok alkinrecall following the holiday or ak iien kakkijke ilo iien spring? Aet Jab

3 - Temporary (120 raan ak diklok jan ) Elaññe aet kwalok raan eo kwon naj rol nan jerbal:

EMPLOYER PHONE: DATE LAST W RK ENDED:

Wawein Bwijrak Jan Jerbal:Kabwijrak Jan Jerbal:

Kamoj Eok make: Rol Jan Jerbal: Rijerbal in Jikuul: Bar Jet Un:

Enana LanEjjelok JerbalEjjemok JerbalEkilok Bejinej

Ew r Kar Am Menin IdinEjmourBar Jet Un

KikiKomman IrreJako/RumijEjjelok kautiej nan RitollIdaak/Uno Ekkajur TestUn KoJet

Spring Kakkije Summer KakkijeHoliday

SuspensionAjej Jerbal Kakkijekilok Jan Jikin JerbalUtame An BaamleMedicalEdiklok Awa in Jerbal Jan (40 awa)

Kakkije Kon NaninmijStrike jan Jerbal HolidaysJerbal Part time Wot

Pad Jikin Tarinae

APPLICATION FOR UNEMPLOYMENT INSURANCE BENEFITS

Marshallese

DWS-ARK-501 v01182020 Page of

* ARMIJEO EAR KOJERBALE EOK: ACCOUNT N MBA (Local Office Only) N MBA IN UNIT: (Local Office Only)

* ETAN STREET:

*CITY: *STATE: *COUNTY: *ZIP CODE:

EMPLOYER PHONE: ORIGINAL HIRE DATE: DATE LAST W RK ENDED:

ELIGIBILITY INFORMATION (*Kadedeik im Kanne aolep Field in Melele Ko )

* Em j an kar bar w r am jabrewot jerbal alkin kar JIKIN JERBAL EO AM AIKTATA Aet Jab* JikinJerbal Eo Am ear ke jipañ Eok Iumin Jidik IIen? Aet Jab

* Kain jerbal rot eo kwar kommane ilo jerbal eo am aliktata?:

JIKINJERBAL EO JUON (*Kadedeik im Kanne aolep Field in Melele Ko)

Kwoj ke bojak nan jikinjerbal ak jino juon jerbal kaal ilowan wot 10 wiik ko? Aet Jab

If yes, date you are scheduled to return to work:

* Jikin jerbal aliktata? 1-Likieo in awa in jerbal (40 hrs) 2-Part time (Edik jan 40 awa)3 - Temporary (120 raan ak diklok jan ) Elaññe aet kwalok raan eo kwon naj rol nan jerbal:

Wawein Bwijrak Jan Jerbal:Kabwijrak Jan Jerbal:

Kamoj Eok make: Rol Jan Jerbal: Rijerbal in Jikuul: Bar Jet Un:

Enana LanEjjelok JerbalEjjemok JerbalEkilok Bejinej

Ew r Kar Am Menin IdinEjmourBar Jet Un

KikiKomman IrreJako/RumijEjjelok kautiej nan RitollIdaak/Uno Ekkajur TestUn KoJet

Spring Kakkije Summer KakkijeHoliday

SuspensionAjej Jerbal Kakkijekilok Jan Jikin JerbalUtame An BaamleMedicalEdiklok Awa in Jerbal Jan (40 awa)

Kakkije Kon NaninmijStrike jan Jerbal HolidaysJerbal Part time Wot

Pad Jikin Tarinae

Kwoj konaan ke bwe ren b k Federal Taxes jan kolle ko am? Aet Jab * Kwoj ke ebb k am jaan jan wwawein kein ilal:

* Kolle Ilo IIen Kakkije? Aet Jab* Kolle ilo Iien Naninmij? Aet Jab* Kolle Eo Aliktata? Aet Jab* Ajejej jan profit ko? Aet Jab* Kolle Ilo IIen Am Bwijrak (Off)? Aet Jab

* Kwoj ke ebb k ak applae nan jaan in retire jan jerbal ko am mokta ak jikin ko jet ekoba social security? (not including social security) Aet Jab* Kwoj maron ke jino jerbal kio kio wot? Aet Jab* Kwoj maron ke jerbal Full Time? Aet Jab* Ew r ke ial nan jikin jerbal eo am ke em j komman kar k nan ial nan kwe? Aet Jab* Ew r ke uame ilo anbwinnum eo enaj bobrae eok jan am maron k an jerbal eo am? Aet Jab

Aet Jab

* Ew r ke nejum ajri/ro jet kwoj lkejparok im lale ir im? Aet Jab* If Elanne aet, em jke am komman kar k nan air lale ir ilo iien am kapok am jerbal?

Em j ke am makoko in b ke jabrewot jerbal akin an jako am kar jerbal? Aet JabEjanin alikar Aet No

Elanne jab, kwoj ke lomnak in naj jikuul? Aet JabAet JabUndecided

Aet JabElanne aet Aet Jab

*2) Ew r ke kein kamool in men eo wonaam eliktata your last earnings? (ES 935 Form) Aet Jab

Aet Jab

* Elaññe Jab, aikuij w r MA - 843* Elaññe Aet, aikuij w r Form 970

Aet Jab

* Elaññe Aet, Etan

Local N mba eo an:

* Ededelok ke am kolle men eo kunam? Aet Jab

Em j ke am jerbal ipp n Kien (Federal Employment) ilo18 allon ko remotlok? (ejab kobatok jerbal in tarinae

* Em j ke am kar juon eo ear jerbal in ritarinae ilo18 Alloñ ko remotlok?

* Kwoj ke elolo am jerbal kon wot Union?

Elanne aet, ew r ke juo raan eo kwoj omnak in jikuu tokalik?

Aet Jab

*1) )Ew r ke am copy in SF-8 or SF-50? (ES 931 Form)

* Elaññe Aet, ew r ke am copy in DD-214 eo am? Aet Jab

* Kwoj ke jerbal ippam make, jerbal kon kontrak ak ilo jikin kaip eo ej b brae eok jan am kappok jikin am jerbal ak jino am jerbal ?

Ij kio je eta nan a jerbal im ikit akile kojjela eo kake an jako aojerbal, im kajjit k kake juon ak kake jimwe ko a ikijien j n in jipañ iumin Kakien iumin Department of W rkforce Services. Ij k an a kar k nan a b k j n in jipañ ko.

REQUALIFYING WAGES: Yes No RETURN DATE: CONTROL DATE: INTERVIEWER'S INITIALS:

LOCAL OFFICE USE ONLY

Jaini Etam: Raan: