Get ND SFN59872 2011

ES-935 CLAIMANT S AFFIDAVIT OF FEDERAL CIVILIAN SERVICE WAGES AND REASON FOR SEPARATION UCFE JSND/UI BENEFITS AREA SFN59872 05/11 State Agency Job Service North Dakota Name First M Last Name Local Office Central Social Security Number Employer Federal Agency Name Place of Employment Address per the SF8 Birthdate 3-Digit Code from the SF8 For Internal Use Only Type of Claim New Additional Date Filed Effective Date Dates of Employment To From City State Contact Telephone Number 701 328. 4995 ZIP Code Gross Wages Received From the Above Agency last 6 months with agency BASE and LAG Period QUARTER ENDING GROSS WAGES HOURS WORKED WEEKS WORKED MAIL CLAIMANTS-Send in with this form and copies of documentation you have showing that you worked for the listed federal agency. This includes SF-50 W-2 forms pay stubs leave and earnings statements payroll change slips or other creditable evidence of wages and reason for separation* These copies become part of your official record. Please DO NOTsend originals unless absolutely necessary originals will be returned to you. Total Lump Sum Payments Received for Annual Leave Amount of Payment Date of Payment Documentary Evidence Submitted by the claimant showing Federal Civilian Employment Amount of Leave Effective Period of Annual Leave Severance Pay Did you receive or are you entitled to receive severance pay provided by any federal law or agency-employee agreement Yes No If yes complete the following information Weekly Amount Total Entitlement Number of Weeks Severance Pay Period Pension Are you entitled to receive a pension from any branch of the Federal Government If yes enter the gross monthly pension Reason for Separation Yes No I the claimant understand 1 That penalties are provided by law for an individual making false statements to obtain benefits 2 That any determination based on this affidavit is not final 3 That it is subject to correction upon receipt of wage and separation information from the federal agency for which I worked 4 That benefit payments made as a result of such determination may have to be adjusted on the basis of information furnished by the federal agency 5 That any amount overpaid may have to be repaid or offset against future benefits. I THE CLAIMANT SWEAR OR AFFIRM THAT THE ABOVE STATEMENTS TO THE BEST OF MY KNOWLEDGE OR BELIEF ARE TRUE AND CORRECT. Signature Date In compliance with the Privacy Act of 1974 a Social Security Number is mandatory on this form pursuant to 20 CFR 666. 150 and/or North Dakota Century Code 52-02-02. This number is used by Job Service North Dakota for identification federal and state tax program eligibility purposes and program performance accountability. Job Service North Dakota is an equal opportunity employer/program provider. Auxiliary aids and services are available upon request to individuals with disabilities. 4995 ZIP Code Gross Wages Received From the Above Agency last 6 months with agency BASE and LAG Period QUARTER ENDING GROSS WAGES HOURS WORKED WEEKS WORKED MAIL CLAIMANTS-Send in with this form and copies of documentation you have showing that you worked for the listed federal agency. This includes SF-50 W-2 forms pay stubs leave and earnings statements payroll change slips or other creditable evidence of wages and reason for separation* These copies become part of your official record. .