UI / DE 1446TRA

SAMPLE, this page for reference only

 

RECORD OF POTENTIAL FAMILY INCOME FOR THE NEXT THREE MONTHS – TAA/TRA

Name:
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Date:
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SSN:
XXX-XX-

Please complete the information requested below for the next three months following the date of this form.

Include receipt of unemployment insurance and disability insurance as income.

Month
and
Year
 
 Your Gross
Income
All Sources
 
 Spouse's
Gross Income
All Sources
 
 Other Income
Available to
the Family
 
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List below as many employers as space allows that you have contacted in your effort to find employment for the last month.
Last work search for period from
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to
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A B C D E F G
Employer Location Date you applied Type of work applied for? How you knew of this employer?
( Want-Ad, friend? )		 Who did you talk to?
(Manager, Supervisor, Foreman, Receptionist?)		 Was any job Offered?
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If you have a definite job promise, enter the date you will start work:
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Name of employer:
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Your signature
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Date
DE 1446TRA Rev. 4 (8-21) (INTRANET)