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 Certificate of Release or Discharge from Active Duty, DD Form 214, to complete this form (if you have a NOAA Form 56-16, it can be used in place of the DD Form 214).
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 Form 214? (Section 3)
 4.
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5.
What is your Pay Grade? (DD Form 214, Section 4b)
 5.
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6.
What is your Entry Date? (DD Form 214, Section 12a)
 6.
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(MM/DD/YYYY)
7.
What is your Separation Date? (DD Form 214, Section 12b)
 7.
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(MM/DD/YYYY)
8.
What is your Net Active Service? (DD Form 214, Section 12c)
 8.
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(MM/DD/YYYY)
9.
What is your Character of Service? (DD Form 214, Section 24)
 9.
10.
What is the Narrative Reason for Separation? (DD Form 214, Section 28)
 10.
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11.
What is your DD 214 Member number? (Located on lower right corner of form)
 11.
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12.
Report all dates of time lost during this period. (DD Form 214, Section 29)
 12.
FROM (MM/DD/YYYY) TO (MM/DD/YYYY)
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DE 1101IAZ (7-11) (INTRANET)