UI / DE 1101IAZ

SAMPLE, this page for reference only

 

UNEMPLOYMENT INSURANCE (UI) APPLICATION

Social Security Number:
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SUPPLEMENTAL FORM FOR EX-SERVICEMEMBERS – ATTACHMENT A

Please refer to your DD-214 (Member 4 or Service), to complete this form. If you have a ‎NOAA 56-16, it can be used in place of the DD-214. If you served in the Air Force and Space Force, please complete a separate Attachment A for each branch.
1.
What is your branch of service?
 1.
2.
Were you in the Reserves?
 2.
3.
Did you complete a first full-term of service?
 3.
4.
What is the Social Security Number on your DD-214?
 4.
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5.
What is your Pay Grade? (DD-214)
 5.
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6.
What is your Entry Date? (DD-214)
 6.
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(YYYY/MM/DD)
7.
What is your Separation Date? (DD-214)
 7.
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(YYYY/MM/DD)
8.
What is your Net Active Service? (DD-214)
 8.
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(YY/MM/DD)
9.
What is your Character of Service? (DD-214)
 9.
10.
What is the Narrative Reason for Separation? (DD-214)
 10.
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11.
What is your DD 214 Member number or Copy name?
(Located on lower right corner of form)
 11.
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12.
Report all dates of time lost during this period. (DD-214)
 12.
FROM (YYYY/MM/DD) TO (YYYY/MM/DD)
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DE 1101IAZ Rev. 1 (5-25) (INTRANET)