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Get NY SW 4 2018-2024

E: Part A – Employee Statement Sunday Week Ending Date Enter the date and answer the questions for the week claimed: 1. Did you work for anyone other than your Shared Work employer on any day in the week? (This includes self-employment.) If “Yes,” complete “a” through “c.” a. How many days did you work? 1 2 3 4 or more b. Excluding earnings from self-employment, did you earn more than $450 during Yes No the week? c. Are you still working for this employer? Yes No If No, complete.

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