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ETA-935 STATE AGENCY IDENTIFICATION CLAIMANT S AFFIDAVIT OF FEDERAL CIVILIAN SERVICE WAGES AND REASON FOR SEPARATION ETA-935 1. State Agency Address 2. Claimant s Name and Mailing Address 3. Local Office/Call Center ID 4. Date of Request 5. Effective Date of Claim 7. Federal Agency Name and Address 6. Separation Date 8. Social Security Number Instructions Complete and Return Immediately 9. Affidavit of Federal Wage and Separation Information/Documentary Evidence a* Enter the location of your Official Duty Station City State b. Enter your wages with the above named employer below. Show wages by quarter starting with the wages that you earned after base period begin date up to the date you separated from this employer. Under Documentary Evidence enter the source of the information provided and attach a copy. If additional space is needed to explain reason for separation attach your signed explanation* Quarter Ending Year Gross Wages Documentary Evidence c* Severance Pay. Did you receive or are you entitled to receive severance pay provided by Federal law or agency employee agreement Yes No If Yes complete the following information Total Entitlement. Severance Pay Period Begin date // Ending Date // d. Pension Are you entitled to receive a pension from any branch of the Federal Government Yes No Enter Gross Monthly Pension. e. Reason for Separation I the claimant understand that penalties are provided by law for an individual making false statements to obtain benefits and that determinations based on an affidavit are not final that determinations are subject to correction upon receipt of wage and separation information from the Federal agency that benefit payments made as a result of such determination may have to be adjusted on the basis of swear or affirm that the above statements to the best of my knowledge are true and correct. State Agency Address 2. Claimant s Name and Mailing Address 3. Local Office/Call Center ID 4. Date of Request 5. Effective Date of Claim 7. Federal Agency Name and Address 6. Separation Date 8. Social Security Number Instructions Complete and Return Immediately 9. Effective Date of Claim 7. Federal Agency Name and Address 6. Separation Date 8. Social Security Number Instructions Complete and Return Immediately 9. Affidavit of Federal Wage and Separation Information/Documentary Evidence a* Enter the location of your Official Duty Station City State b. Affidavit of Federal Wage and Separation Information/Documentary Evidence a* Enter the location of your Official Duty Station City State b. Enter your wages with the above named employer below. Show wages by quarter starting with the wages that you earned after base period begin date up to the date you separated from this employer. Enter your wages with the above named employer below. Show wages by quarter starting with the wages that you earned after base period begin date up to the date you separated from this employer. Under Documentary Evidence enter the source of the information provided and attach a copy. If additional space is needed to explain reason for separation attach your signed explanation* Quarter Ending Year Gross Wages Documentary Evidence c* Severance Pay. .

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