UI / DE 4581FO

SAMPLE, this page for reference only

Continued Claim

FOR OFFICE USE ONLY - DO NOT WRITE IN THIS SPACE
SSN
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Program Code
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BYB
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Take Waiting Period
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IMPORTANT - CAREFULLY ANSWER ALL QUESTIONS
 
 
Print your name and Social Security Number on both sides of this form. SEE SECTION A. ON BACK FOR EXAMPLES OF HOW TO COMPLETE YOUR ANSWERS.

Each question is explained in your booklet, A Guide to Benefits and Employment Services.

Claimant Name:
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Social Security Number:
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-
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-
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COMPLETE AND MAIL THIS FORM ON
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1ST WEEK ENDS
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2ND WEEK ENDS
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YES NO YES NO
1. Were you too sick or injured to work?
  If yes, enter the number of days (1 through 7) you were unable to work
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(1-7)
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(1-7)
2. Was there any reason (other than sickness or injury) that you could not have accepted full-time work each workday?
3. Did you look for work?
← IF MARKED 'X,' YOU MUST COMPLETE SEC. B, WORK-SEARCH RECORD, ON REVERSE.
4. Did you refuse any work?
5. Did you begin attending any kind of school or training?
6. Did you work or earn any money, WHETHER YOU WERE PAID OR NOT? 
(If yes, you MUST COMPLETE items a. and b. below.)
a. Enter earnings before deductions here $
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 $
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b. Report employment or 'source' of earnings information below:
DATE LAST WORKED TOTAL HOURS WORKED EMPLOYER NAME AND MAILING ADDRESS - INCLUDE ZIP CODE REASON NO LONGER WORKING (OR WRITE "STILL WORKING")
1ST WEEK Blank space  Blank space  Blank space  Blank space 
2ND WEEK Blank space  Blank space  Blank space  Blank space 
7. If you want federal income tax withheld for the week(s) shown above, mark this block
8. If you had a change of mailing address or phone number, mark this block and complete Sec. D on reverse
 
I understand the questions on this form. I know the law provides penalties if I make false statements or withhold facts to receive benefits; my answers are true and correct. I declare under penalty of perjury that I am a U.S. citizen or national; or an alien in satisfactory immigration status and permitted to work by USCIS. I signed this form after the latest date for which I am claiming benefits.
X
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(your signature is required)

DE 4581FO Rev. 4 (12-04) (INTRANET)

SAMPLE, this page for reference only

Name:
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Social Security Number:
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-
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Section A

The following are examples of how to complete your answers to the questions on the front of this form.

MARK THE CORRECT ANSWER
EXAMPLE:
IF THE ANSWER IS "YES":
Yes
No
IF THE ANSWER IS "NO":
Yes
No
Write numbers like this: ‎ 0 1 2 3 4 5 6 7 8 9
EXAMPLE: If you want to write the number "$342.58" it should look like this:
$
3
4
2
 
5
8
If you want to write the number "$76.10" it should look like this:
$
 
7
6
 
1
0
Report earnings of $1,000.00 or more as "$999.99", like this:
$
9
9
9
 
9
9

Section B

If the box under Question 3 on the reverse is marked "X", you must complete the table below to show your work search for the weeks being claimed.

WORK-SEARCH RECORD
Date Applied Company Name Company Address Person Contacted Type of Work Applied For Results: Please Explain
Blank space  Blank space  Blank space  Blank space  Blank space  Blank space 
Blank space  Blank space  Blank space  Blank space  Blank space  Blank space 
Blank space  Blank space  Blank space  Blank space  Blank space  Blank space 
Blank space  Blank space  Blank space  Blank space  Blank space  Blank space 
Blank space  Blank space  Blank space  Blank space  Blank space  Blank space 
Blank space  Blank space  Blank space  Blank space  Blank space  Blank space 
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Section C

Notice to Educational Institution (FOR EMPLOYMENT DEVELOPMENT DEPARTMENT APPROVED TRAINING ONLY)

I certify that this individual was enrolled in and satisfactorily pursuing the retraining course of instruction approved by the Employment Development Department during the week(s) shown on the front of this form.
Signature/Title
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Date
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Name of Training Institution
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If you are on a semester/holiday recess, enter the date you are scheduled to return to school.
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Section D: Complete below and mark Question 8 block on front.

NEW MAILING ADDRESS: Street or Box NumberBlank Space
City and StateBlank Space ZIP Code:Blank Space
NEW PHONE NUMBER - INCLUDE AREA CODE:
( )
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DE 4581FO Rev. 4 (12-04) (INTRANET)