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Get IN 54244 / DWD 640P 2012

UNEMPLOYMENT INSURANCE PROTEST EMPLOYER State Form 54244 R3 / 4-12 DWD 640P INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT CONFIDENTIAL RECORD PURSUANT TO IC 22-4-19-6 IC 4-1-6 This agency is requesting the disclosure of your Social Security Number in accordance with IC 4-1-8-1 disclosure is mandatory and this record cannot be processed without it. Claimant Name Social Security Number Benefit Year End Claimant Street Address City State and ZIP Code Employer Indiana SUTA Employer Account Number Employer Address City State and ZIP Code Employee worked from // to last day worked mm/dd/yyyy Reason for Protest Check all that apply School Worker - Code 70 Quit - Code 10 this could include job abandonment stopped showing up retired employee personal reasons no contact to check on further assignments etc*. Discharge for Cause - Code 20 or attendance sleeping on the job documented poor performance policy violations etc*. Gross Misconduct - Code 30 this is defined by Ind. Code 22-4-15-6. 1 and would include an employee committing a crime that would be considered a Felony or Class A Misdemeanor being intoxicated committing battery fraud or other situations involving theft or embezzlement. Check this box if the employer is a school and has offered the claimant reasonable assurance to return to work after the most recent customary recess. Employment Status - Code 70 never worked for the employer is still employed in the same job under generally the same terms or otherwise not unemployed by the employer or a planned plant shut down. Work Refusal Failed Drug Test - Code 70 work or if the individual refused to take or failed a pre-employment drug test. Did the claimant receive income upon separation or thereafter Vacation Please note You will receive additional requests from the UI Adjudication Center seeking specific details concerning the employee s separation* Please respond to these requests as quickly as possible. Failure to respond to requests from the department can result in a penalty even if the employee is later determined ineligible. Brief Statement of Facts regarding separation Employer Contact Name Date Employer Signature Check here if you are attaching additional supporting documents to this fax total number of additional pages Fax Form to UI Adjudications at 317-233-5499. Claimant Name Social Security Number Benefit Year End Claimant Street Address City State and ZIP Code Employer Indiana SUTA Employer Account Number Employer Address City State and ZIP Code Employee worked from // to last day worked mm/dd/yyyy Reason for Protest Check all that apply School Worker - Code 70 Quit - Code 10 this could include job abandonment stopped showing up retired employee personal reasons no contact to check on further assignments etc*. Discharge for Cause - Code 20 or attendance sleeping on the job documented poor performance policy violations etc*. Discharge for Cause - Code 20 or attendance sleeping on the job documented poor performance policy violations etc*. Gross Misconduct - Code 30 this is defined by Ind. Code 22-4-15-6. 1 and would include an employee committing a crime that would be considered a Felony or Class A Misdemeanor being intoxicated committing battery fraud or other situations involving theft or embezzlement. .

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