District Office Record of Determinations as to Voluntary Quit

I 1. SSA No.
DISTRICT OFFICE RECORD OF
DETERMINATIONS AS TO VOLUNTARY QUIT

2. Claimant's Name

3. lnformation About Leavina Work

a. Date left work:
b. Em~lover:
c.

Occu~ation:

Reason for leavina work:
Bv Claimant:
Bv Emplover (If employer statement not obtained, explain why):

4.

Determinations bv District Office
a. Leaving was:
1.

Not Voluntary (Provide AIM/FOM reference, explain itf full the &termination, and go to ltem 4.C.):

2.

Voluntary
a.
b.

With Good Cause (Provide AllWFOM reference, explain, and go to ltem 4.6.):
Without Good Cause (Provide AIWFOM reference, explain, and go to ltem 4.C.):

b. Entitlement to Other Unemployment Benefits
UI-45 shows clearly not qualified.
Statement from other agency shows clearly not qualified.
Claimant apparently qualified but has exhausted rights.
lnformation that claimant could receive other benefits (Explain source and show the period):
Other (Explain):
c.

Determined by:

Date: 1211612005

Reviewed by:

Date:

i. Date disqualification period ended:

.

Are there qualifying railroad wages after voluntary quit?

Yes

No

letermined by:

Date:

teviewed by:

Date:

USTRUCTIONS: Use the next page to record any pertinent information other than called for above. If a determination is
ater reversed or modified, show basis and who made the redetermination.