UI / DE 1101IBZ

SAMPLE, this page for reference only

 

UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number:
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SUPPLEMENTAL FORM FOR FEDERAL EMPLOYEES –ATTACHMENT B

Please complete the following:
1.
Did you work for the Federal Emergency Management Agency (FEMA) as a Disaster Assistance Employee (DAE)?
 1.
2.
What is your state of residence?
 2.
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3.
What is the complete name of the federal agency for your last official duty station?
 3
Name:
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a)
What is the complete address of the federal agency for your last official duty station?
 a)
Address:
Street:
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City:
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State:
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ZIP Code:
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4.
What is your employer’s three-digit Federal Identification Code (FIC) located on your W-2, SF 8 or SF 50?
 4
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a)
What is the federal agency name and address on your W-2, SF 8 or SF 50?
 a)
Name:
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Address:
Street:
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City:
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State:
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ZIP Code:
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5.
Have you had subsequent employment since your federal employment?
 5.
a)
If yes, in what state was your subsequent employment?
 a)
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DE 1101IBZ (7-11) (INTRANET)