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PREDECESSOR ACCOUNT NO. CLAIM DATE E *IF INFORMATION ABOUT WAGES IS CORRECT AND YOU DO NOT WISH TO REQUEST A RULING, NO FURTHER ACTION IS NECESSARY. THIS FORM IS FOR YOUR RECORDS. THE PERSON NAMED BELOW HAS RECEIVED UI BENEFITS BASED IN TOTAL OR IN PART ON WAGES YOU REPORTED. NAME WAGES REPORTED UNDER SOCIAL SECURITY NUMBER OTHER SOCIAL SECURITY NUMBER PL CLAIMANT S NAME WAGES YOU REPORTED BY QUARTER USED TO ESTABLISH THIS CLAIM (BASED ON ) FOR INFORMATION REGARDING BASE PERIOD, SEE.

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