unemployment insurance agency extended benefits (eb) packet

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UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET Rick Synder Governor Steve Arwood Director Steve Hilfinger Director State of Michigan Department of Licensing and Regulatory Affairs Unemployment Insurance Company Cadillac Place 3024 W. Grand Blvd. Detroit, MI 48202

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Page 1: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

UNEMPLOYMENT INSURANCE AGENCYEXTENDED BENEFITS (EB) PACKET

Rick SynderGovernor

Steve ArwoodDirector

Steve HilfingerDirector

State of MichiganDepartment of Licensing and Regulatory Affairs

Unemployment Insurance CompanyCadillac Place

3024 W. Grand Blvd.Detroit, MI 48202

Page 2: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

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Page 3: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

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UIA 1960(Rev. 12-11)

State of MichiganDepartment of Licensing and Regulatory Affairs

UNEMPLOYMENT INSURANCE AGENCYwww.michigan.gov/uia

Purpose of the Michigan Extended Benefi ts Program

The purpose of the Extended Benefi ts (EB) program is to pay unemployment benefi ts during periods of high unemployment to workers, including federal civilian employees and ex-military personnel, who exhausted their basic entitlement to regular state and federal unemployment benefi ts.

The cost of Extended Benefi ts paid from 1-25-09 through 2-21-09 will be shared 50/50 by the federal government and Michigan employers. Effective 2-22-09, the American Recovery and Reinvestment Act of 2009 established that the federal government will pay 100% of the cost of EB. The exceptions are governmental entities, Indian Tribes and Tribal Units that are charged 100% of all extended benefi ts.

Some Questions and Answers About the Michigan Extended Benefi ts Program

1. Who is entitled to Extended Benefi ts?

You may be entitled to EB if you:a) Are unemployed or underemployed,b) Had established eligibility for regular state or federal unemployment benefi ts, have

exhausted those benefi ts and exhausted all entitlement to Emergency Unemployment Compensation (EUC).

c) Exhausted all benefi t all UI including all EUC benefi t entitlement prior to 1-25-09 and have a BYE of 1/31/2009 or later.

d) Do not have available regular benefi ts under the unemployment compensation laws of any state, the Virgin Islands, Puerto Rico, Canada, the District of Columbia, or the federal government of the United States.

e) Meet the eligibility requirements of the law and are not disqualifi ed.

Not everyone is entitled to Extended Benefi ts. For example, an individual who was disqualifi ed on their regular unemployment claim for one of the following reasons will not be eligible for Extended Benefi ts: refusal of work, imprisonment, labor dispute, assault and battery, theft, willful destruction, failure to notify a temporary help fi rm, or illegal drugs.

2. What does it mean to have “exhausted” my benefi ts?

For purposes of the Michigan EB program, you have exhausted your rights to regular unemployment benefi ts and EUC when: a) you have received all the benefi ts to which you were entitled in a benefi t year under a regular state or federal program; OR b) your benefi t year has expired before you have drawn all your benefi ts and no new benefi t year can be established.

EXTENDED BENEFITS EXTENDED BENEFITS EXTENDED BENEFITS EXTENDED

EXTENDED BENEFITS EXTENDED BENEFITS EXTENDED BENEFITS EXTENDEDEXTE

ND

ED B

ENEFITS

Authorized by MCL 421.1, et seq.

Extended Benefi ts (EB) ProgramRights & Responsibilities

Page 4: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

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3. What is an Extended Benefit period?

Until recently, Extended Benefits (EB) provided up to 13 weeks of additional Unemployment Insurance (UI) benefits to workers who exhausted their regular benefits (maximum 26 weeks). EB is paid only when a state’s unemployment rate rises to a level sufficient to “trigger” the program and start benefit extensions. There are two ways EB triggers on, the Insured Unemployment Rate (IUR) and the Total Unemployment Rate (TUR).

IUR – Michigan triggered on with week beginning January 4, 2009. The first week payable for EB is beginning January 25, 2009. Under the IUR, claimants receive a maximum of 50% of their regular unemployment benefit entitlement.

TUR – The Michigan Employment Security Act was amended effective April 13, 2009, to include the Total Unemployment Rate (TUR) triggering factor. If the state exceeds the 6.5% TUR, unemployed workers are entitled up to 13 weeks of EB. If the state exceeds 8.0% unemployment, unemployed workers are entitled to receive 80% of their regular state unemployment insurance benefits for up to 20 weeks of EB.

Michigan has met the TUR of 8.0%, which entitles claimants to receive up to 80% of their unemployment insurance benefits for a maximum of 20 weeks of benefits. All initial EB monetary determination issued on April 13, 2009 and forward will be calculated at 80% of the unemployed worker’s regular state benefits, instead of 50%.

4. How much will I receive under this program and for how long?

When an EB period is in effect and you have exhausted your regular benefits, you may be eligible to receive EB amounting to 80% of your regular state benefit entitlement for a maximum of 20 weeks.

Example 1: If your Michigan determination was for $2,600 ($100 a week for 26 weeks), your EB could be $2080 ($104 a week for 20 weeks).

Example 2: If your Michigan determination was for $4,000 ($200 a week for 20 weeks), your EB will be $3,200 ($160 a week for 16 weeks).

Regardless of the number of weeks you are entitled to, you cannot be paid EB after an EB period ends.

5. What other requirements must I meet to be eligible for Extended Benefits?

Your eligibility for EB will be determined in the same manner as were your rights to regular state or federal benefits. You must be unemployed or underemployed, and be able to work and available for work.

You must have a verified registration for work (resume) on file with the Michigan Works! Agency (MWA) BEFORE reporting using MARVIN to claim your first week of EB. The MWA will notify the UIA that you have registered for work. For MWA locations, call 1-800-285-WORK.

You must also certify for benefit entitlement on your appointment day and time using MARVIN, either by telephone at 1-866-638-3993, or online at http://www.michigan.gov/uia, and select the link, “MARVIN Online” under “UIA Online Services for Unemployed Workers.” You must be diligently seeking work during each week for which you are claiming EB. See “Special EB Work Search Requirements” below.

Special EB Work Search Requirement, Including Form UIA 1583An unemployed worker eligible for EB must make a more diligent search for work than would normally be required if you were receiving regular unemployment benefits. You must make a systematic and sustained effort to obtain work during each week you are claiming Extended Benefits. Federal guidelines define a systematic and sustained search for work, as a planned, methodical search for work conducted throughout each week claimed for EB (or as the criteria set forth by the state workforce agency for the various labor markets within the state). You must seek work with at least 2 employers in each week

Page 5: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

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If you are claiming Extended Benefi ts by calling MARVIN at 1-866-638-3993: You must complete FormUIA 1583, listing on this form the places where you looked for work each week and give details and results of each work search contact. The completed, signed, and dated form must be mailed or faxed to the UIA BEFORE you call MARVIN for the weeks involved in the work search.

If you are claiming Extended Benefi ts by using MARVIN Online at http://www.michigan.gov/uia: You must submit your work search efforts on a different link on UIA’s web site for the two-week period you areclaiming EB. Access the UIA web site and click on the link, “UIA Online Services for Unemployed Workers” and follow the instructions. You must give details and results of each work search contact for the two-week period you are claiming. This must be done at the same time you certify (claim benefi ts) using MARVIN Online.If you’ve been approved by the UIA to use paper certifi cation forms (sent in by mail or fax): You must complete Form UIA 1583. You are required to list on this form the places where you looked for work and give details and results of each work search contact. The completed, signed, and dated Form UIA 1583 must be returned with your certifi cation form.

If you are in training approved by a Michigan Works Agency! Service Center: You should continue tocertify by mail and attach your training attendance form. You do not need to complete Form UIA 1583 for any week that you are attending approved training.

SUITABLE WORK: The law provides that after fi ling your claim for EB, you must apply for and accept any suitable work as defi ned below:

Under the requirements of federal law relating to the EB Program, suitable work is any work you are capable of doing. If you refuse any job within your capability, you will be disqualifi ed if:

a) The gross weekly pay offered is more than your EB weekly benefi t rate plus any SUB pay you receive from your former employer; and

b) The offered pay is at least the federal minimum wage; andc) The offer is either in writing or the job is listed by the employer with Michigan Works!

6. Under what circumstances would I be disqualifi ed for Extended Benefi ts?

You are subject to the same disqualifi cations under the EB program as under Michigan’s regular benefi ts program. In addition, the law provides that you must be disqualifi ed from EB if you do not meet the seeking work requirements, or if you fail to apply for, interview, or accept, suitable work. If disqualifi ed, the only way you can again become entitled to EB is to get a job, work for at least 4 weeks and earn at least 4 times your EB weekly benefi t amount. If you did not seek work during a week, you should elect not to claim EB for that week. By claiming that week, you will be disqualifi ed for further benefi ts until you work for 4 weeks and earn at least 4 times your EB weekly benefi t amount.

7. When will Extended Benefi ts start?

Extended Benefi t payments may be made only during an EB period and can be made for any weeks that begin prior to the ending date of an EB period. The law permitting EB payments in Michigan was effective with the week ending 1/10/2009 and thereafter. The fi rst payable week begins 1/25/2009.

8. When will an Extended Benefi t period end?

The EB period will end whenever the state Insured Unemployment Rate (IUR) drops below the EB trigger levels or the Total Unemployment Rate drops below 8.0% in Michigan (see Item 3). However, once an EB period begins, it will continue for at least 13 consecutive weeks. A new EB period cannot begin with a state trigger until the 14th week after the end of a prior EB period.

you are claiming benefi ts. You must report to the UIA your work search efforts for each week you claim Extended Benefi ts.

Page 6: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

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LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

The information in this pamphlet is meant to assist informing you of your rights to Extended Benefi ts. It does not have the force of law or rule. If you have any additional questions, call our toll-free number at 1-866-500-0017 (TTY callers use 1-866-366-0004) Monday through Friday between 8:00 A.M. and 4:30 P.M. (Eastern Time).

9. What will happen to my Extended Benefi ts if new regular state or federal benefi t rights become available to me?

Any time you become eligible for regular state or federal benefi ts, you must fi le a new claim for regular benefi ts and your eligibility for EB will end. If an EB period is in effect when you exhaust regular benefi ts, you may again qualify for EB based on a new claim.

10. How do federal Extended Unemployment Compensation (EUC) benefi ts affect Extended Benefi ts?

You must exhaust all EUC benefi t entitlement before you may be eligible for Extended Benefi ts.

11. How do I apply for Extended Benefi ts?

A notice regarding possible eligibility for EB is automatically mailed to unemployed workers who may meet the requirements for qualifying for EB (outlined in #1 of this handout). If you receive such notice, and are unemployed or underemployed at this time, you may qualify for EB. To qualify, you must apply for benefi ts on the UIA’s web site, http://www.michigan.gov/uia, Monday 7:00 A.M. THROUGH Saturday 7:00 P.M. Eastern Time. Click on the “File a EUC or EB Extension” link, which is on the home page. If you are unable to apply for EB online, call us at 1-866-500-0017, and choose option #3. Filing a claim by telephone is available from 8:00 AM to 4:30 PM, Monday through Wednesday, Eastern Time, according to your social security number at the phone number above. If you missed your appointment day and time, you can fi le by telephone at 1-866-500-0017 any time between 8:00 A.M. and 4:30 P.M.* on Thursday or Friday of that same week.

IMPORTANT: Interstate EB claims against Michigan and other states may be fi led in the same manner as regular interstate claims. However, although Michigan may have an EB period in effect, some states may not. The law provides that any unemployed worker who fi les a new, additional, or continued interstate claim for EB in another state that is not in an EB period must be limited to a maximum payment of only two weeks.

12. Will I have the right of appeal under the Extended Benefi t program?

Yes. You have the same appeal rights under the EB program as under the regular benefi t program.

13. Does the law provide any penalties?

Yes, under 18 U.S.C. Section 1001, knowingly and willfully concealing a material fact by any trick, scheme, or device or knowingly making a false statement in connection with this claim is a federal offense, punishable by a fi ne of not more than $10,000 or imprisonment for not more than fi ve years, or both. You will be required to pay back any benefi ts improperly received plus any applicable penalties. If, by mistake, you gave incorrect information when you fi led your claim, notify us as soon as you realize it, in order to avoid penalties.

Page 7: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

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Page 8: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

Instructions for Completing the EB Work Search

The following information must be completed on the Work Search form in order to continue to receive EB payments.

• Week Ending Dates – these dates are for the previous two weeks. The dates start on Sunday and end on Saturday. Write the Saturday date for each week.

• Date of Contact – the dates of your work search must fall within the week ending (Sunday thru Saturday) date for each week.

• Name of Employer – write the name, if known, or the online job search site, or employment service or agency that was contacted. If the employer is not known or not identifi ed, indicate “not known or not identifi ed.”

• Employer(s) Address – enter the employer address, or city/state, web site address, general location, or indicate “not known”.

• Name and Title of Person Contacted – enter the name and title, if known of the person contacted, or the area contracted (e.g., human resources department, web site address), or indicate not known.”

• Method of Contact – enter how contact was made, (e.g., in person, phone, mail, fax, e-mail, online, by resume, response to job ad, etc.)

• Type of Work Applied for - enter the type of work applied for, (e.g., factory worker, retail sales, wait staff, truck driver, etc.)

• Results – enter results of work search, (e.g., submitted resume and/or application, not accepting applications, not hiring, scheduled for interview, etc.)

IMPORTANT NOTE ABOUT NUMBER OF WORK SEARCHES PER WEEK –You must list at least 2 employers each week. The third employer contact is optional, but only 2 employer contacts per week are required.

If you have questions regarding the EB work search, call our toll free telephone inquiry line at 1-866-500-0017 and press option 3 to speak with an agent.

UIA 1583(Rev. 05-11)Reverse Side

Page 9: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

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ny q

uest

ions

abo

ut th

is fo

rm o

r E

B w

ork

sear

ch r

equi

rem

ents

, cal

l us

at 1

-866

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-001

7 (T

TY c

usto

mer

s us

e 1-

866-

366-

0004

) be

twee

n 8:

00 A

M a

nd 4

:30

PM

(E

aste

rn T

ime)

Mon

day

thro

ugh

Frid

ay.

Det

aile

d in

stru

ctio

ns o

n re

vers

e si

de.

For U

IA U

se O

nly

Use

r I.D

.: __

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____

____

___

D

ate:

___

____

____

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LAR

A is

an

equa

l opp

ortu

nity

em

ploy

er/p

rogr

am.

Firs

t Wee

k E

ndin

g D

ate:

___

____

____

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Sec

ond

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ate:

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e of

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licat

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not h

iring

, etc

.)

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . .

. . .

. . .

. . .

. . . . . . . . . .

. . .

. . . . . . .

. . .

. . .

. . .

. . .

. . .

. . .

Mai

l or f

ax th

is fo

rm to

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nem

ploy

men

t Ins

uran

ce A

genc

yP.

O. B

ox 1

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rand

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ids,

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4950

1-01

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x: 1

-517

- 636

-042

7

Dat

e M

aile

d/Fa

xed

____

____

____

_

–see

oth

er si

de–

Page 10: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

Instructions for Completing the EB Work Search

The following information must be completed on the Work Search form in order to continue to receive EB payments.

• Week Ending Dates – these dates are for the previous two weeks. The dates start on Sunday and end on Saturday. Write the Saturday date for each week.

• Date of Contact – the dates of your work search must fall within the week ending (Sunday thru Saturday) date for each week.

• Name of Employer – write the name, if known, or the online job search site, or employment service or agency that was contacted. If the employer is not known or not identifi ed, indicate “not known or not identifi ed.”

• Employer(s) Address – enter the employer address, or city/state, web site address, general location, or indicate “not known”.

• Name and Title of Person Contacted – enter the name and title, if known of the person contacted, or the area contracted (e.g., human resources department, web site address), or indicate not known.”

• Method of Contact – enter how contact was made, (e.g., in person, phone, mail, fax, e-mail, online, by resume, response to job ad, etc.)

• Type of Work Applied for - enter the type of work applied for, (e.g., factory worker, retail sales, wait staff, truck driver, etc.)

• Results – enter results of work search, (e.g., submitted resume and/or application, not accepting applications, not hiring, scheduled for interview, etc.)

IMPORTANT NOTE ABOUT NUMBER OF WORK SEARCHES PER WEEK –You must list at least 2 employers each week. The third employer contact is optional, but only 2 employer contacts per week are required.

If you have questions regarding the EB work search, call our toll free telephone inquiry line at 1-866-500-0017 and press option 3 to speak with an agent.

UIA 1583(Rev. 05-11)Reverse Side

Page 11: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

UIA

158

3(R

ev. 0

5-11

)A

utho

rized

by

MC

L 42

1.1,

et s

eq.

Stat

e of

Mic

higa

nD

epar

tmen

t of L

icen

sing

and

Reg

ulat

ory

Aff

airs

UN

EMPL

OY

MEN

T IN

SUR

AN

CE

AG

ENC

Yw

ww

.mic

higa

n.go

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a

Wee

kly

Ext

ende

d B

enefi

ts

(EB

) R

ecor

d of

Wor

k S

earc

h Ent

er y

our

Soci

al S

ecur

ity n

umbe

r

Your

Cer

tifi c

atio

n: B

y si

gnin

g th

is fo

rm, I

am

rep

ortin

g m

y w

ork

sear

ches

for

the

wee

k(s)

sho

wn

abov

e. T

he in

form

atio

n re

porte

d on

this

form

is tr

ue a

nd

corr

ect t

o th

e be

st o

f my

know

ledg

e an

d be

lief.

Und

er 1

8 U

.S.C

. Sec

tion

1001

, kno

win

gly

and

will

fully

con

ceal

ing

a m

ater

ial f

act b

y an

y tri

ck, s

chem

e, o

r dev

ice

or k

now

ingl

y m

akin

g a

fals

e st

atem

ent i

n co

nnec

tion

with

this

cla

im is

a fe

dera

l offe

nse,

pun

isha

ble

by a

fi ne

of n

ot m

ore

than

$10

,000

or

impr

ison

men

t for

no

t mor

e th

an fi

ve y

ears

, or b

oth.

Sig

natu

re:_

____

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____

____

____

____

____

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____

____

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____

____

____

____

Dat

e:__

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ase

prin

t cle

arly

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use

bla

ck in

k)N

am

e: __

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____

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*015831105*

IMPO

RTA

NT:

O

ne o

f the

req

uire

men

ts to

be

elig

ible

for

Ext

ende

d B

enefi

ts (

EB

) is

that

you

mus

t mak

e a

syst

emat

ic a

nd s

usta

ined

effo

rt to

fi nd

wor

k fo

r ea

ch w

eek

you

are

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min

g E

B.

You

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t con

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oyer

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our w

ork

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ch e

fforts

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s. Y

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an d

o th

is b

y:(1

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ordi

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our w

ork

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ch e

fforts

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rm to

the

addr

ess

or fa

x nu

mbe

r sho

wn

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e B

EFO

RE

you

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RV

IN fo

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riod

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R

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f you

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d M

AR

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to c

laim

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ende

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enefi

ts fo

r the

pre

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s tw

o w

eek

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d, y

ou m

ust r

epor

t you

r wor

k se

arch

effo

rts o

n ou

r web

site

at

http

://w

ww

.mic

higa

n.go

v/ui

a.

If yo

u ha

ve a

ny q

uest

ions

abo

ut th

is fo

rm o

r E

B w

ork

sear

ch r

equi

rem

ents

, cal

l us

at 1

-866

-500

-001

7 (T

TY c

usto

mer

s us

e 1-

866-

366-

0004

) be

twee

n 8:

00 A

M a

nd 4

:30

PM

(E

aste

rn T

ime)

Mon

day

thro

ugh

Frid

ay.

Det

aile

d in

stru

ctio

ns o

n re

vers

e si

de.

For U

IA U

se O

nly

Use

r I.D

.: __

____

____

____

____

___

D

ate:

___

____

____

___

LAR

A is

an

equa

l opp

ortu

nity

em

ploy

er/p

rogr

am.

Firs

t Wee

k E

ndin

g D

ate:

___

____

____

____

___

Sec

ond

Wee

k E

ndin

g D

ate:

___

____

____

____

___

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e of

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e of

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mpl

oyer

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pplie

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r

Res

ult

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licat

ion

subm

it-te

d, in

terv

iew

, hiri

ng,

not h

iring

, etc

.)

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . .

. . .

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. . .

. . . . . . . . . .

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. . . . . . .

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. . .

. . .

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. . .

. . .

Mai

l or f

ax th

is fo

rm to

:U

nem

ploy

men

t Ins

uran

ce A

genc

yP.

O. B

ox 1

69G

rand

Rap

ids,

MI

4950

1-01

69Fa

x: 1

-517

- 636

-042

7

Dat

e M

aile

d/Fa

xed

____

____

____

_

–see

oth

er si

de–

Page 12: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

Instructions for Completing the EB Work Search

The following information must be completed on the Work Search form in order to continue to receive EB payments.

• Week Ending Dates – these dates are for the previous two weeks. The dates start on Sunday and end on Saturday. Write the Saturday date for each week.

• Date of Contact – the dates of your work search must fall within the week ending (Sunday thru Saturday) date for each week.

• Name of Employer – write the name, if known, or the online job search site, or employment service or agency that was contacted. If the employer is not known or not identifi ed, indicate “not known or not identifi ed.”

• Employer(s) Address – enter the employer address, or city/state, web site address, general location, or indicate “not known”.

• Name and Title of Person Contacted – enter the name and title, if known of the person contacted, or the area contracted (e.g., human resources department, web site address), or indicate not known.”

• Method of Contact – enter how contact was made, (e.g., in person, phone, mail, fax, e-mail, online, by resume, response to job ad, etc.)

• Type of Work Applied for - enter the type of work applied for, (e.g., factory worker, retail sales, wait staff, truck driver, etc.)

• Results – enter results of work search, (e.g., submitted resume and/or application, not accepting applications, not hiring, scheduled for interview, etc.)

IMPORTANT NOTE ABOUT NUMBER OF WORK SEARCHES PER WEEK –You must list at least 2 employers each week. The third employer contact is optional, but only 2 employer contacts per week are required.

If you have questions regarding the EB work search, call our toll free telephone inquiry line at 1-866-500-0017 and press option 3 to speak with an agent.

UIA 1583(Rev. 05-11)Reverse Side

Page 13: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

UIA

158

3(R

ev. 0

5-11

)A

utho

rized

by

MC

L 42

1.1,

et s

eq.

Stat

e of

Mic

higa

nD

epar

tmen

t of L

icen

sing

and

Reg

ulat

ory

Aff

airs

UN

EMPL

OY

MEN

T IN

SUR

AN

CE

AG

ENC

Yw

ww

.mic

higa

n.go

v/ui

a

Wee

kly

Ext

ende

d B

enefi

ts

(EB

) R

ecor

d of

Wor

k S

earc

h Ent

er y

our

Soci

al S

ecur

ity n

umbe

r

Your

Cer

tifi c

atio

n: B

y si

gnin

g th

is fo

rm, I

am

rep

ortin

g m

y w

ork

sear

ches

for

the

wee

k(s)

sho

wn

abov

e. T

he in

form

atio

n re

porte

d on

this

form

is tr

ue a

nd

corr

ect t

o th

e be

st o

f my

know

ledg

e an

d be

lief.

Und

er 1

8 U

.S.C

. Sec

tion

1001

, kno

win

gly

and

will

fully

con

ceal

ing

a m

ater

ial f

act b

y an

y tri

ck, s

chem

e, o

r dev

ice

or k

now

ingl

y m

akin

g a

fals

e st

atem

ent i

n co

nnec

tion

with

this

cla

im is

a fe

dera

l offe

nse,

pun

isha

ble

by a

fi ne

of n

ot m

ore

than

$10

,000

or

impr

ison

men

t for

no

t mor

e th

an fi

ve y

ears

, or b

oth.

Sig

natu

re:_

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

Dat

e:__

____

____

____

____

____

(Ple

ase

prin

t cle

arly

and

use

bla

ck in

k)N

am

e: __

____

____

____

____

____

____

____

____

____

____

__

*015831105*

IMPO

RTA

NT:

O

ne o

f the

req

uire

men

ts to

be

elig

ible

for

Ext

ende

d B

enefi

ts (

EB

) is

that

you

mus

t mak

e a

syst

emat

ic a

nd s

usta

ined

effo

rt to

fi nd

wor

k fo

r ea

ch w

eek

you

are

clai

min

g E

B.

You

mus

t con

tact

a m

inim

um o

f 2 e

mpl

oyer

s pe

r wee

k, a

nd re

port

the

deta

ils a

nd re

sults

of y

our w

ork

sear

ch e

fforts

to u

s. Y

ou c

an d

o th

is b

y:(1

) Rec

ordi

ng y

our w

ork

sear

ch e

fforts

on

this

form

and

then

mai

l or f

ax th

is fo

rm to

the

addr

ess

or fa

x nu

mbe

r sho

wn

abov

e B

EFO

RE

you

call

MA

RV

IN fo

r the

two-

wee

k pe

riod

cove

red

by th

is fo

rm, O

R

(2) I

f you

use

d M

AR

VIN

Onl

ine

to c

laim

Ext

ende

d B

enefi

ts fo

r the

pre

viou

s tw

o w

eek

perio

d, y

ou m

ust r

epor

t you

r wor

k se

arch

effo

rts o

n ou

r web

site

at

http

://w

ww

.mic

higa

n.go

v/ui

a.

If yo

u ha

ve a

ny q

uest

ions

abo

ut th

is fo

rm o

r E

B w

ork

sear

ch r

equi

rem

ents

, cal

l us

at 1

-866

-500

-001

7 (T

TY c

usto

mer

s us

e 1-

866-

366-

0004

) be

twee

n 8:

00 A

M a

nd 4

:30

PM

(E

aste

rn T

ime)

Mon

day

thro

ugh

Frid

ay.

Det

aile

d in

stru

ctio

ns o

n re

vers

e si

de.

For U

IA U

se O

nly

Use

r I.D

.: __

____

____

____

____

___

D

ate:

___

____

____

___

LAR

A is

an

equa

l opp

ortu

nity

em

ploy

er/p

rogr

am.

Firs

t Wee

k E

ndin

g D

ate:

___

____

____

____

___

Sec

ond

Wee

k E

ndin

g D

ate:

___

____

____

____

___

Dat

e of

Con

tact

Nam

e of

Em

ploy

erE

mpl

oyer

(s)

Ad

dres

sN

ame

and

Tit

le o

f P

erso

n C

onta

cted

Met

hod

of

Con

tact

Typ

e of

wor

k A

pplie

d fo

r

Res

ult

(App

licat

ion

subm

it-te

d, in

terv

iew

, hiri

ng,

not h

iring

, etc

.)

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . .

. . .

. . .

. . .

. . . . . . . . . .

. . .

. . . . . . .

. . .

. . .

. . .

. . .

. . .

. . .

Mai

l or f

ax th

is fo

rm to

:U

nem

ploy

men

t Ins

uran

ce A

genc

yP.

O. B

ox 1

69G

rand

Rap

ids,

MI

4950

1-01

69Fa

x: 1

-517

- 636

-042

7

Dat

e M

aile

d/Fa

xed

____

____

____

_

–see

oth

er si

de–

Page 14: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

Instructions for Completing the EB Work Search

The following information must be completed on the Work Search form in order to continue to receive EB payments.

• Week Ending Dates – these dates are for the previous two weeks. The dates start on Sunday and end on Saturday. Write the Saturday date for each week.

• Date of Contact – the dates of your work search must fall within the week ending (Sunday thru Saturday) date for each week.

• Name of Employer – write the name, if known, or the online job search site, or employment service or agency that was contacted. If the employer is not known or not identifi ed, indicate “not known or not identifi ed.”

• Employer(s) Address – enter the employer address, or city/state, web site address, general location, or indicate “not known”.

• Name and Title of Person Contacted – enter the name and title, if known of the person contacted, or the area contracted (e.g., human resources department, web site address), or indicate not known.”

• Method of Contact – enter how contact was made, (e.g., in person, phone, mail, fax, e-mail, online, by resume, response to job ad, etc.)

• Type of Work Applied for - enter the type of work applied for, (e.g., factory worker, retail sales, wait staff, truck driver, etc.)

• Results – enter results of work search, (e.g., submitted resume and/or application, not accepting applications, not hiring, scheduled for interview, etc.)

IMPORTANT NOTE ABOUT NUMBER OF WORK SEARCHES PER WEEK –You must list at least 2 employers each week. The third employer contact is optional, but only 2 employer contacts per week are required.

If you have questions regarding the EB work search, call our toll free telephone inquiry line at 1-866-500-0017 and press option 3 to speak with an agent.

UIA 1583(Rev. 05-11)Reverse Side

Page 15: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

UIA

158

3(R

ev. 0

5-11

)A

utho

rized

by

MC

L 42

1.1,

et s

eq.

Stat

e of

Mic

higa

nD

epar

tmen

t of L

icen

sing

and

Reg

ulat

ory

Aff

airs

UN

EMPL

OY

MEN

T IN

SUR

AN

CE

AG

ENC

Yw

ww

.mic

higa

n.go

v/ui

a

Wee

kly

Ext

ende

d B

enefi

ts

(EB

) R

ecor

d of

Wor

k S

earc

h Ent

er y

our

Soci

al S

ecur

ity n

umbe

r

Your

Cer

tifi c

atio

n: B

y si

gnin

g th

is fo

rm, I

am

rep

ortin

g m

y w

ork

sear

ches

for

the

wee

k(s)

sho

wn

abov

e. T

he in

form

atio

n re

porte

d on

this

form

is tr

ue a

nd

corr

ect t

o th

e be

st o

f my

know

ledg

e an

d be

lief.

Und

er 1

8 U

.S.C

. Sec

tion

1001

, kno

win

gly

and

will

fully

con

ceal

ing

a m

ater

ial f

act b

y an

y tri

ck, s

chem

e, o

r dev

ice

or k

now

ingl

y m

akin

g a

fals

e st

atem

ent i

n co

nnec

tion

with

this

cla

im is

a fe

dera

l offe

nse,

pun

isha

ble

by a

fi ne

of n

ot m

ore

than

$10

,000

or

impr

ison

men

t for

no

t mor

e th

an fi

ve y

ears

, or b

oth.

Sig

natu

re:_

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

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e:__

____

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ase

prin

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arly

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use

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ck in

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e: __

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____

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____

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IMPO

RTA

NT:

O

ne o

f the

req

uire

men

ts to

be

elig

ible

for

Ext

ende

d B

enefi

ts (

EB

) is

that

you

mus

t mak

e a

syst

emat

ic a

nd s

usta

ined

effo

rt to

fi nd

wor

k fo

r ea

ch w

eek

you

are

clai

min

g E

B.

You

mus

t con

tact

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inim

um o

f 2 e

mpl

oyer

s pe

r wee

k, a

nd re

port

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deta

ils a

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sults

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our w

ork

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ch e

fforts

to u

s. Y

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an d

o th

is b

y:(1

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ordi

ng y

our w

ork

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ch e

fforts

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this

form

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l or f

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rm to

the

addr

ess

or fa

x nu

mbe

r sho

wn

abov

e B

EFO

RE

you

call

MA

RV

IN fo

r the

two-

wee

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riod

cove

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is fo

rm, O

R

(2) I

f you

use

d M

AR

VIN

Onl

ine

to c

laim

Ext

ende

d B

enefi

ts fo

r the

pre

viou

s tw

o w

eek

perio

d, y

ou m

ust r

epor

t you

r wor

k se

arch

effo

rts o

n ou

r web

site

at

http

://w

ww

.mic

higa

n.go

v/ui

a.

If yo

u ha

ve a

ny q

uest

ions

abo

ut th

is fo

rm o

r E

B w

ork

sear

ch r

equi

rem

ents

, cal

l us

at 1

-866

-500

-001

7 (T

TY c

usto

mer

s us

e 1-

866-

366-

0004

) be

twee

n 8:

00 A

M a

nd 4

:30

PM

(E

aste

rn T

ime)

Mon

day

thro

ugh

Frid

ay.

Det

aile

d in

stru

ctio

ns o

n re

vers

e si

de.

For U

IA U

se O

nly

Use

r I.D

.: __

____

____

____

____

___

D

ate:

___

____

____

___

LAR

A is

an

equa

l opp

ortu

nity

em

ploy

er/p

rogr

am.

Firs

t Wee

k E

ndin

g D

ate:

___

____

____

____

___

Sec

ond

Wee

k E

ndin

g D

ate:

___

____

____

____

___

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e of

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licat

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subm

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terv

iew

, hiri

ng,

not h

iring

, etc

.)

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . .

. . .

. . .

. . .

. . . . . . . . . .

. . .

. . . . . . .

. . .

. . .

. . .

. . .

. . .

. . .

Mai

l or f

ax th

is fo

rm to

:U

nem

ploy

men

t Ins

uran

ce A

genc

yP.

O. B

ox 1

69G

rand

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ids,

MI

4950

1-01

69Fa

x: 1

-517

- 636

-042

7

Dat

e M

aile

d/Fa

xed

____

____

____

_

–see

oth

er si

de–

Page 16: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

Instructions for Completing the EB Work Search

The following information must be completed on the Work Search form in order to continue to receive EB payments.

• Week Ending Dates – these dates are for the previous two weeks. The dates start on Sunday and end on Saturday. Write the Saturday date for each week.

• Date of Contact – the dates of your work search must fall within the week ending (Sunday thru Saturday) date for each week.

• Name of Employer – write the name, if known, or the online job search site, or employment service or agency that was contacted. If the employer is not known or not identifi ed, indicate “not known or not identifi ed.”

• Employer(s) Address – enter the employer address, or city/state, web site address, general location, or indicate “not known”.

• Name and Title of Person Contacted – enter the name and title, if known of the person contacted, or the area contracted (e.g., human resources department, web site address), or indicate not known.”

• Method of Contact – enter how contact was made, (e.g., in person, phone, mail, fax, e-mail, online, by resume, response to job ad, etc.)

• Type of Work Applied for - enter the type of work applied for, (e.g., factory worker, retail sales, wait staff, truck driver, etc.)

• Results – enter results of work search, (e.g., submitted resume and/or application, not accepting applications, not hiring, scheduled for interview, etc.)

IMPORTANT NOTE ABOUT NUMBER OF WORK SEARCHES PER WEEK –You must list at least 2 employers each week. The third employer contact is optional, but only 2 employer contacts per week are required.

If you have questions regarding the EB work search, call our toll free telephone inquiry line at 1-866-500-0017 and press option 3 to speak with an agent.

UIA 1583(Rev. 05-11)Reverse Side

Page 17: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

UIA

158

3(R

ev. 0

5-11

)A

utho

rized

by

MC

L 42

1.1,

et s

eq.

Stat

e of

Mic

higa

nD

epar

tmen

t of L

icen

sing

and

Reg

ulat

ory

Aff

airs

UN

EMPL

OY

MEN

T IN

SUR

AN

CE

AG

ENC

Yw

ww

.mic

higa

n.go

v/ui

a

Wee

kly

Ext

ende

d B

enefi

ts

(EB

) R

ecor

d of

Wor

k S

earc

h Ent

er y

our

Soci

al S

ecur

ity n

umbe

r

Your

Cer

tifi c

atio

n: B

y si

gnin

g th

is fo

rm, I

am

rep

ortin

g m

y w

ork

sear

ches

for

the

wee

k(s)

sho

wn

abov

e. T

he in

form

atio

n re

porte

d on

this

form

is tr

ue a

nd

corr

ect t

o th

e be

st o

f my

know

ledg

e an

d be

lief.

Und

er 1

8 U

.S.C

. Sec

tion

1001

, kno

win

gly

and

will

fully

con

ceal

ing

a m

ater

ial f

act b

y an

y tri

ck, s

chem

e, o

r dev

ice

or k

now

ingl

y m

akin

g a

fals

e st

atem

ent i

n co

nnec

tion

with

this

cla

im is

a fe

dera

l offe

nse,

pun

isha

ble

by a

fi ne

of n

ot m

ore

than

$10

,000

or

impr

ison

men

t for

no

t mor

e th

an fi

ve y

ears

, or b

oth.

Sig

natu

re:_

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

Dat

e:__

____

____

____

____

____

(Ple

ase

prin

t cle

arly

and

use

bla

ck in

k)N

am

e: __

____

____

____

____

____

____

____

____

____

____

__

*015831105*

IMPO

RTA

NT:

O

ne o

f the

req

uire

men

ts to

be

elig

ible

for

Ext

ende

d B

enefi

ts (

EB

) is

that

you

mus

t mak

e a

syst

emat

ic a

nd s

usta

ined

effo

rt to

fi nd

wor

k fo

r ea

ch w

eek

you

are

clai

min

g E

B.

You

mus

t con

tact

a m

inim

um o

f 2 e

mpl

oyer

s pe

r wee

k, a

nd re

port

the

deta

ils a

nd re

sults

of y

our w

ork

sear

ch e

fforts

to u

s. Y

ou c

an d

o th

is b

y:(1

) Rec

ordi

ng y

our w

ork

sear

ch e

fforts

on

this

form

and

then

mai

l or f

ax th

is fo

rm to

the

addr

ess

or fa

x nu

mbe

r sho

wn

abov

e B

EFO

RE

you

call

MA

RV

IN fo

r the

two-

wee

k pe

riod

cove

red

by th

is fo

rm, O

R

(2) I

f you

use

d M

AR

VIN

Onl

ine

to c

laim

Ext

ende

d B

enefi

ts fo

r the

pre

viou

s tw

o w

eek

perio

d, y

ou m

ust r

epor

t you

r wor

k se

arch

effo

rts o

n ou

r web

site

at

http

://w

ww

.mic

higa

n.go

v/ui

a.

If yo

u ha

ve a

ny q

uest

ions

abo

ut th

is fo

rm o

r E

B w

ork

sear

ch r

equi

rem

ents

, cal

l us

at 1

-866

-500

-001

7 (T

TY c

usto

mer

s us

e 1-

866-

366-

0004

) be

twee

n 8:

00 A

M a

nd 4

:30

PM

(E

aste

rn T

ime)

Mon

day

thro

ugh

Frid

ay.

Det

aile

d in

stru

ctio

ns o

n re

vers

e si

de.

For U

IA U

se O

nly

Use

r I.D

.: __

____

____

____

____

___

D

ate:

___

____

____

___

LAR

A is

an

equa

l opp

ortu

nity

em

ploy

er/p

rogr

am.

Firs

t Wee

k E

ndin

g D

ate:

___

____

____

____

___

Sec

ond

Wee

k E

ndin

g D

ate:

___

____

____

____

___

Dat

e of

Con

tact

Nam

e of

Em

ploy

erE

mpl

oyer

(s)

Ad

dres

sN

ame

and

Tit

le o

f P

erso

n C

onta

cted

Met

hod

of

Con

tact

Typ

e of

wor

k A

pplie

d fo

r

Res

ult

(App

licat

ion

subm

it-te

d, in

terv

iew

, hiri

ng,

not h

iring

, etc

.)

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . .

. . .

. . .

. . .

. . . . . . . . . .

. . .

. . . . . . .

. . .

. . .

. . .

. . .

. . .

. . .

Mai

l or f

ax th

is fo

rm to

:U

nem

ploy

men

t Ins

uran

ce A

genc

yP.

O. B

ox 1

69G

rand

Rap

ids,

MI

4950

1-01

69Fa

x: 1

-517

- 636

-042

7

Dat

e M

aile

d/Fa

xed

____

____

____

_

–see

oth

er si

de–

Page 18: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

Instructions for Completing the EB Work Search

The following information must be completed on the Work Search form in order to continue to receive EB payments.

• Week Ending Dates – these dates are for the previous two weeks. The dates start on Sunday and end on Saturday. Write the Saturday date for each week.

• Date of Contact – the dates of your work search must fall within the week ending (Sunday thru Saturday) date for each week.

• Name of Employer – write the name, if known, or the online job search site, or employment service or agency that was contacted. If the employer is not known or not identifi ed, indicate “not known or not identifi ed.”

• Employer(s) Address – enter the employer address, or city/state, web site address, general location, or indicate “not known”.

• Name and Title of Person Contacted – enter the name and title, if known of the person contacted, or the area contracted (e.g., human resources department, web site address), or indicate not known.”

• Method of Contact – enter how contact was made, (e.g., in person, phone, mail, fax, e-mail, online, by resume, response to job ad, etc.)

• Type of Work Applied for - enter the type of work applied for, (e.g., factory worker, retail sales, wait staff, truck driver, etc.)

• Results – enter results of work search, (e.g., submitted resume and/or application, not accepting applications, not hiring, scheduled for interview, etc.)

IMPORTANT NOTE ABOUT NUMBER OF WORK SEARCHES PER WEEK –You must list at least 2 employers each week. The third employer contact is optional, but only 2 employer contacts per week are required.

If you have questions regarding the EB work search, call our toll free telephone inquiry line at 1-866-500-0017 and press option 3 to speak with an agent.

UIA 1583(Rev. 05-11)Reverse Side

Page 19: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

UIA

158

3(R

ev. 0

5-11

)A

utho

rized

by

MC

L 42

1.1,

et s

eq.

Stat

e of

Mic

higa

nD

epar

tmen

t of L

icen

sing

and

Reg

ulat

ory

Aff

airs

UN

EMPL

OY

MEN

T IN

SUR

AN

CE

AG

ENC

Yw

ww

.mic

higa

n.go

v/ui

a

Wee

kly

Ext

ende

d B

enefi

ts

(EB

) R

ecor

d of

Wor

k S

earc

h Ent

er y

our

Soci

al S

ecur

ity n

umbe

r

Your

Cer

tifi c

atio

n: B

y si

gnin

g th

is fo

rm, I

am

rep

ortin

g m

y w

ork

sear

ches

for

the

wee

k(s)

sho

wn

abov

e. T

he in

form

atio

n re

porte

d on

this

form

is tr

ue a

nd

corr

ect t

o th

e be

st o

f my

know

ledg

e an

d be

lief.

Und

er 1

8 U

.S.C

. Sec

tion

1001

, kno

win

gly

and

will

fully

con

ceal

ing

a m

ater

ial f

act b

y an

y tri

ck, s

chem

e, o

r dev

ice

or k

now

ingl

y m

akin

g a

fals

e st

atem

ent i

n co

nnec

tion

with

this

cla

im is

a fe

dera

l offe

nse,

pun

isha

ble

by a

fi ne

of n

ot m

ore

than

$10

,000

or

impr

ison

men

t for

no

t mor

e th

an fi

ve y

ears

, or b

oth.

Sig

natu

re:_

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

Dat

e:__

____

____

____

____

____

(Ple

ase

prin

t cle

arly

and

use

bla

ck in

k)N

am

e: __

____

____

____

____

____

____

____

____

____

____

__

*015831105*

IMPO

RTA

NT:

O

ne o

f the

req

uire

men

ts to

be

elig

ible

for

Ext

ende

d B

enefi

ts (

EB

) is

that

you

mus

t mak

e a

syst

emat

ic a

nd s

usta

ined

effo

rt to

fi nd

wor

k fo

r ea

ch w

eek

you

are

clai

min

g E

B.

You

mus

t con

tact

a m

inim

um o

f 2 e

mpl

oyer

s pe

r wee

k, a

nd re

port

the

deta

ils a

nd re

sults

of y

our w

ork

sear

ch e

fforts

to u

s. Y

ou c

an d

o th

is b

y:(1

) Rec

ordi

ng y

our w

ork

sear

ch e

fforts

on

this

form

and

then

mai

l or f

ax th

is fo

rm to

the

addr

ess

or fa

x nu

mbe

r sho

wn

abov

e B

EFO

RE

you

call

MA

RV

IN fo

r the

two-

wee

k pe

riod

cove

red

by th

is fo

rm, O

R

(2) I

f you

use

d M

AR

VIN

Onl

ine

to c

laim

Ext

ende

d B

enefi

ts fo

r the

pre

viou

s tw

o w

eek

perio

d, y

ou m

ust r

epor

t you

r wor

k se

arch

effo

rts o

n ou

r web

site

at

http

://w

ww

.mic

higa

n.go

v/ui

a.

If yo

u ha

ve a

ny q

uest

ions

abo

ut th

is fo

rm o

r E

B w

ork

sear

ch r

equi

rem

ents

, cal

l us

at 1

-866

-500

-001

7 (T

TY c

usto

mer

s us

e 1-

866-

366-

0004

) be

twee

n 8:

00 A

M a

nd 4

:30

PM

(E

aste

rn T

ime)

Mon

day

thro

ugh

Frid

ay.

Det

aile

d in

stru

ctio

ns o

n re

vers

e si

de.

For U

IA U

se O

nly

Use

r I.D

.: __

____

____

____

____

___

D

ate:

___

____

____

___

LAR

A is

an

equa

l opp

ortu

nity

em

ploy

er/p

rogr

am.

Firs

t Wee

k E

ndin

g D

ate:

___

____

____

____

___

Sec

ond

Wee

k E

ndin

g D

ate:

___

____

____

____

___

Dat

e of

Con

tact

Nam

e of

Em

ploy

erE

mpl

oyer

(s)

Ad

dres

sN

ame

and

Tit

le o

f P

erso

n C

onta

cted

Met

hod

of

Con

tact

Typ

e of

wor

k A

pplie

d fo

r

Res

ult

(App

licat

ion

subm

it-te

d, in

terv

iew

, hiri

ng,

not h

iring

, etc

.)

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . .

. . .

. . .

. . .

. . . . . . . . . .

. . .

. . . . . . .

. . .

. . .

. . .

. . .

. . .

. . .

Mai

l or f

ax th

is fo

rm to

:U

nem

ploy

men

t Ins

uran

ce A

genc

yP.

O. B

ox 1

69G

rand

Rap

ids,

MI

4950

1-01

69Fa

x: 1

-517

- 636

-042

7

Dat

e M

aile

d/Fa

xed

____

____

____

_

–see

oth

er si

de–

Page 20: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

Instructions for Completing the EB Work Search

The following information must be completed on the Work Search form in order to continue to receive EB payments.

• Week Ending Dates – these dates are for the previous two weeks. The dates start on Sunday and end on Saturday. Write the Saturday date for each week.

• Date of Contact – the dates of your work search must fall within the week ending (Sunday thru Saturday) date for each week.

• Name of Employer – write the name, if known, or the online job search site, or employment service or agency that was contacted. If the employer is not known or not identifi ed, indicate “not known or not identifi ed.”

• Employer(s) Address – enter the employer address, or city/state, web site address, general location, or indicate “not known”.

• Name and Title of Person Contacted – enter the name and title, if known of the person contacted, or the area contracted (e.g., human resources department, web site address), or indicate not known.”

• Method of Contact – enter how contact was made, (e.g., in person, phone, mail, fax, e-mail, online, by resume, response to job ad, etc.)

• Type of Work Applied for - enter the type of work applied for, (e.g., factory worker, retail sales, wait staff, truck driver, etc.)

• Results – enter results of work search, (e.g., submitted resume and/or application, not accepting applications, not hiring, scheduled for interview, etc.)

IMPORTANT NOTE ABOUT NUMBER OF WORK SEARCHES PER WEEK –You must list at least 2 employers each week. The third employer contact is optional, but only 2 employer contacts per week are required.

If you have questions regarding the EB work search, call our toll free telephone inquiry line at 1-866-500-0017 and press option 3 to speak with an agent.

UIA 1583(Rev. 05-11)Reverse Side

Page 21: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

UIA

158

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ev. 0

5-11

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MC

L 42

1.1,

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eq.

Stat

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earc

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er y

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Soci

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ecur

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Your

Cer

tifi c

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g th

is fo

rm, I

am

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ortin

g m

y w

ork

sear

ches

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wee

k(s)

sho

wn

abov

e. T

he in

form

atio

n re

porte

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this

form

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ue a

nd

corr

ect t

o th

e be

st o

f my

know

ledg

e an

d be

lief.

Und

er 1

8 U

.S.C

. Sec

tion

1001

, kno

win

gly

and

will

fully

con

ceal

ing

a m

ater

ial f

act b

y an

y tri

ck, s

chem

e, o

r dev

ice

or k

now

ingl

y m

akin

g a

fals

e st

atem

ent i

n co

nnec

tion

with

this

cla

im is

a fe

dera

l offe

nse,

pun

isha

ble

by a

fi ne

of n

ot m

ore

than

$10

,000

or

impr

ison

men

t for

no

t mor

e th

an fi

ve y

ears

, or b

oth.

Sig

natu

re:_

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____

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____

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e:__

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uire

men

ts to

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ible

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ende

d B

enefi

ts (

EB

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that

you

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t mak

e a

syst

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usta

ined

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rt to

fi nd

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you

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x nu

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e B

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ende

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o w

eek

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ou m

ust r

epor

t you

r wor

k se

arch

effo

rts o

n ou

r web

site

at

http

://w

ww

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n.go

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u ha

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uest

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ut th

is fo

rm o

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B w

ork

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ch r

equi

rem

ents

, cal

l us

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TY c

usto

mer

s us

e 1-

866-

366-

0004

) be

twee

n 8:

00 A

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nd 4

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PM

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aste

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ime)

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day

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ploy

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rogr

am.

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t Wee

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e M

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____

____

____

_

–see

oth

er si

de–

Page 22: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

Instructions for Completing the EB Work Search

The following information must be completed on the Work Search form in order to continue to receive EB payments.

• Week Ending Dates – these dates are for the previous two weeks. The dates start on Sunday and end on Saturday. Write the Saturday date for each week.

• Date of Contact – the dates of your work search must fall within the week ending (Sunday thru Saturday) date for each week.

• Name of Employer – write the name, if known, or the online job search site, or employment service or agency that was contacted. If the employer is not known or not identifi ed, indicate “not known or not identifi ed.”

• Employer(s) Address – enter the employer address, or city/state, web site address, general location, or indicate “not known”.

• Name and Title of Person Contacted – enter the name and title, if known of the person contacted, or the area contracted (e.g., human resources department, web site address), or indicate not known.”

• Method of Contact – enter how contact was made, (e.g., in person, phone, mail, fax, e-mail, online, by resume, response to job ad, etc.)

• Type of Work Applied for - enter the type of work applied for, (e.g., factory worker, retail sales, wait staff, truck driver, etc.)

• Results – enter results of work search, (e.g., submitted resume and/or application, not accepting applications, not hiring, scheduled for interview, etc.)

IMPORTANT NOTE ABOUT NUMBER OF WORK SEARCHES PER WEEK –You must list at least 2 employers each week. The third employer contact is optional, but only 2 employer contacts per week are required.

If you have questions regarding the EB work search, call our toll free telephone inquiry line at 1-866-500-0017 and press option 3 to speak with an agent.

UIA 1583(Rev. 05-11)Reverse Side

Page 23: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

UIA

158

3(R

ev. 0

5-11

)A

utho

rized

by

MC

L 42

1.1,

et s

eq.

Stat

e of

Mic

higa

nD

epar

tmen

t of L

icen

sing

and

Reg

ulat

ory

Aff

airs

UN

EMPL

OY

MEN

T IN

SUR

AN

CE

AG

ENC

Yw

ww

.mic

higa

n.go

v/ui

a

Wee

kly

Ext

ende

d B

enefi

ts

(EB

) R

ecor

d of

Wor

k S

earc

h Ent

er y

our

Soci

al S

ecur

ity n

umbe

r

Your

Cer

tifi c

atio

n: B

y si

gnin

g th

is fo

rm, I

am

rep

ortin

g m

y w

ork

sear

ches

for

the

wee

k(s)

sho

wn

abov

e. T

he in

form

atio

n re

porte

d on

this

form

is tr

ue a

nd

corr

ect t

o th

e be

st o

f my

know

ledg

e an

d be

lief.

Und

er 1

8 U

.S.C

. Sec

tion

1001

, kno

win

gly

and

will

fully

con

ceal

ing

a m

ater

ial f

act b

y an

y tri

ck, s

chem

e, o

r dev

ice

or k

now

ingl

y m

akin

g a

fals

e st

atem

ent i

n co

nnec

tion

with

this

cla

im is

a fe

dera

l offe

nse,

pun

isha

ble

by a

fi ne

of n

ot m

ore

than

$10

,000

or

impr

ison

men

t for

no

t mor

e th

an fi

ve y

ears

, or b

oth.

Sig

natu

re:_

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

Dat

e:__

____

____

____

____

____

(Ple

ase

prin

t cle

arly

and

use

bla

ck in

k)N

am

e: __

____

____

____

____

____

____

____

____

____

____

__

*015831105*

IMPO

RTA

NT:

O

ne o

f the

req

uire

men

ts to

be

elig

ible

for

Ext

ende

d B

enefi

ts (

EB

) is

that

you

mus

t mak

e a

syst

emat

ic a

nd s

usta

ined

effo

rt to

fi nd

wor

k fo

r ea

ch w

eek

you

are

clai

min

g E

B.

You

mus

t con

tact

a m

inim

um o

f 2 e

mpl

oyer

s pe

r wee

k, a

nd re

port

the

deta

ils a

nd re

sults

of y

our w

ork

sear

ch e

fforts

to u

s. Y

ou c

an d

o th

is b

y:(1

) Rec

ordi

ng y

our w

ork

sear

ch e

fforts

on

this

form

and

then

mai

l or f

ax th

is fo

rm to

the

addr

ess

or fa

x nu

mbe

r sho

wn

abov

e B

EFO

RE

you

call

MA

RV

IN fo

r the

two-

wee

k pe

riod

cove

red

by th

is fo

rm, O

R

(2) I

f you

use

d M

AR

VIN

Onl

ine

to c

laim

Ext

ende

d B

enefi

ts fo

r the

pre

viou

s tw

o w

eek

perio

d, y

ou m

ust r

epor

t you

r wor

k se

arch

effo

rts o

n ou

r web

site

at

http

://w

ww

.mic

higa

n.go

v/ui

a.

If yo

u ha

ve a

ny q

uest

ions

abo

ut th

is fo

rm o

r E

B w

ork

sear

ch r

equi

rem

ents

, cal

l us

at 1

-866

-500

-001

7 (T

TY c

usto

mer

s us

e 1-

866-

366-

0004

) be

twee

n 8:

00 A

M a

nd 4

:30

PM

(E

aste

rn T

ime)

Mon

day

thro

ugh

Frid

ay.

Det

aile

d in

stru

ctio

ns o

n re

vers

e si

de.

For U

IA U

se O

nly

Use

r I.D

.: __

____

____

____

____

___

D

ate:

___

____

____

___

LAR

A is

an

equa

l opp

ortu

nity

em

ploy

er/p

rogr

am.

Firs

t Wee

k E

ndin

g D

ate:

___

____

____

____

___

Sec

ond

Wee

k E

ndin

g D

ate:

___

____

____

____

___

Dat

e of

Con

tact

Nam

e of

Em

ploy

erE

mpl

oyer

(s)

Ad

dres

sN

ame

and

Tit

le o

f P

erso

n C

onta

cted

Met

hod

of

Con

tact

Typ

e of

wor

k A

pplie

d fo

r

Res

ult

(App

licat

ion

subm

it-te

d, in

terv

iew

, hiri

ng,

not h

iring

, etc

.)

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

. . . . . . . . . .

. . .

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. . . . . . . . . .

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. . . . . . . . . .

. . .

. . .

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. . .

. . . . . . . . . .

. . .

. . . . . . .

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. . .

. . .

. . .

. . .

. . .

Mai

l or f

ax th

is fo

rm to

:U

nem

ploy

men

t Ins

uran

ce A

genc

yP.

O. B

ox 1

69G

rand

Rap

ids,

MI

4950

1-01

69Fa

x: 1

-517

- 636

-042

7

Dat

e M

aile

d/Fa

xed

____

____

____

_

–see

oth

er si

de–

Page 24: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

Instructions for Completing the EB Work Search

The following information must be completed on the Work Search form in order to continue to receive EB payments.

• Week Ending Dates – these dates are for the previous two weeks. The dates start on Sunday and end on Saturday. Write the Saturday date for each week.

• Date of Contact – the dates of your work search must fall within the week ending (Sunday thru Saturday) date for each week.

• Name of Employer – write the name, if known, or the online job search site, or employment service or agency that was contacted. If the employer is not known or not identifi ed, indicate “not known or not identifi ed.”

• Employer(s) Address – enter the employer address, or city/state, web site address, general location, or indicate “not known”.

• Name and Title of Person Contacted – enter the name and title, if known of the person contacted, or the area contracted (e.g., human resources department, web site address), or indicate not known.”

• Method of Contact – enter how contact was made, (e.g., in person, phone, mail, fax, e-mail, online, by resume, response to job ad, etc.)

• Type of Work Applied for - enter the type of work applied for, (e.g., factory worker, retail sales, wait staff, truck driver, etc.)

• Results – enter results of work search, (e.g., submitted resume and/or application, not accepting applications, not hiring, scheduled for interview, etc.)

IMPORTANT NOTE ABOUT NUMBER OF WORK SEARCHES PER WEEK –You must list at least 2 employers each week. The third employer contact is optional, but only 2 employer contacts per week are required.

If you have questions regarding the EB work search, call our toll free telephone inquiry line at 1-866-500-0017 and press option 3 to speak with an agent.

UIA 1583(Rev. 05-11)Reverse Side

Page 25: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

UIA

158

3(R

ev. 0

5-11

)A

utho

rized

by

MC

L 42

1.1,

et s

eq.

Stat

e of

Mic

higa

nD

epar

tmen

t of L

icen

sing

and

Reg

ulat

ory

Aff

airs

UN

EMPL

OY

MEN

T IN

SUR

AN

CE

AG

ENC

Yw

ww

.mic

higa

n.go

v/ui

a

Wee

kly

Ext

ende

d B

enefi

ts

(EB

) R

ecor

d of

Wor

k S

earc

h Ent

er y

our

Soci

al S

ecur

ity n

umbe

r

Your

Cer

tifi c

atio

n: B

y si

gnin

g th

is fo

rm, I

am

rep

ortin

g m

y w

ork

sear

ches

for

the

wee

k(s)

sho

wn

abov

e. T

he in

form

atio

n re

porte

d on

this

form

is tr

ue a

nd

corr

ect t

o th

e be

st o

f my

know

ledg

e an

d be

lief.

Und

er 1

8 U

.S.C

. Sec

tion

1001

, kno

win

gly

and

will

fully

con

ceal

ing

a m

ater

ial f

act b

y an

y tri

ck, s

chem

e, o

r dev

ice

or k

now

ingl

y m

akin

g a

fals

e st

atem

ent i

n co

nnec

tion

with

this

cla

im is

a fe

dera

l offe

nse,

pun

isha

ble

by a

fi ne

of n

ot m

ore

than

$10

,000

or

impr

ison

men

t for

no

t mor

e th

an fi

ve y

ears

, or b

oth.

Sig

natu

re:_

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

Dat

e:__

____

____

____

____

____

(Ple

ase

prin

t cle

arly

and

use

bla

ck in

k)N

am

e: __

____

____

____

____

____

____

____

____

____

____

__

*015831105*

IMPO

RTA

NT:

O

ne o

f the

req

uire

men

ts to

be

elig

ible

for

Ext

ende

d B

enefi

ts (

EB

) is

that

you

mus

t mak

e a

syst

emat

ic a

nd s

usta

ined

effo

rt to

fi nd

wor

k fo

r ea

ch w

eek

you

are

clai

min

g E

B.

You

mus

t con

tact

a m

inim

um o

f 2 e

mpl

oyer

s pe

r wee

k, a

nd re

port

the

deta

ils a

nd re

sults

of y

our w

ork

sear

ch e

fforts

to u

s. Y

ou c

an d

o th

is b

y:(1

) Rec

ordi

ng y

our w

ork

sear

ch e

fforts

on

this

form

and

then

mai

l or f

ax th

is fo

rm to

the

addr

ess

or fa

x nu

mbe

r sho

wn

abov

e B

EFO

RE

you

call

MA

RV

IN fo

r the

two-

wee

k pe

riod

cove

red

by th

is fo

rm, O

R

(2) I

f you

use

d M

AR

VIN

Onl

ine

to c

laim

Ext

ende

d B

enefi

ts fo

r the

pre

viou

s tw

o w

eek

perio

d, y

ou m

ust r

epor

t you

r wor

k se

arch

effo

rts o

n ou

r web

site

at

http

://w

ww

.mic

higa

n.go

v/ui

a.

If yo

u ha

ve a

ny q

uest

ions

abo

ut th

is fo

rm o

r E

B w

ork

sear

ch r

equi

rem

ents

, cal

l us

at 1

-866

-500

-001

7 (T

TY c

usto

mer

s us

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Page 26: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

Instructions for Completing the EB Work Search

The following information must be completed on the Work Search form in order to continue to receive EB payments.

• Week Ending Dates – these dates are for the previous two weeks. The dates start on Sunday and end on Saturday. Write the Saturday date for each week.

• Date of Contact – the dates of your work search must fall within the week ending (Sunday thru Saturday) date for each week.

• Name of Employer – write the name, if known, or the online job search site, or employment service or agency that was contacted. If the employer is not known or not identifi ed, indicate “not known or not identifi ed.”

• Employer(s) Address – enter the employer address, or city/state, web site address, general location, or indicate “not known”.

• Name and Title of Person Contacted – enter the name and title, if known of the person contacted, or the area contracted (e.g., human resources department, web site address), or indicate not known.”

• Method of Contact – enter how contact was made, (e.g., in person, phone, mail, fax, e-mail, online, by resume, response to job ad, etc.)

• Type of Work Applied for - enter the type of work applied for, (e.g., factory worker, retail sales, wait staff, truck driver, etc.)

• Results – enter results of work search, (e.g., submitted resume and/or application, not accepting applications, not hiring, scheduled for interview, etc.)

IMPORTANT NOTE ABOUT NUMBER OF WORK SEARCHES PER WEEK –You must list at least 2 employers each week. The third employer contact is optional, but only 2 employer contacts per week are required.

If you have questions regarding the EB work search, call our toll free telephone inquiry line at 1-866-500-0017 and press option 3 to speak with an agent.

UIA 1583(Rev. 05-11)Reverse Side

Page 27: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

THIS PAGE LEFT INTENTIONALLY BLANK

Page 28: UNEMPLOYMENT INSURANCE AGENCY EXTENDED BENEFITS (EB) PACKET

State of MichiganDepartment of Licensing and Regulatory Affairs

Unemployment Insurance AgencyCadillac Place

3024 W. Grand Blvd. • Detroit, MI 48202UIA Web Site: www.michigan.gov/uiaThe UIA is ADA and EEO compliant.

Authority: MCL 421.1, et seq.Quantity: $0 – Cost: $0 – Cost per Copy: 0¢

Paid for with Federal funds.LARA is an equal opportunity employer/program.

Rick Synder, Governor Steve Hilfinger, Director

UIA 1960(Rev. 12-11)

State of MichiganDepartment of Licensing and Regulatory AffairsUnemployment Insurance AgencyCadillac Place3024 W. Grand Blvd.Detroit, MI 48202

FIRST CLASS MAILUS POSTAGE PAID

DETROIT MIPERMIT NO. 504

FIRST CLASS