Unemployment Compensation for Federal Employees

(STATE AGENCY IDENTIFICATION) REQUEST FOR WAGE AND SEPARATION INFORMATION- UCFE
1. State Agency Address:	2. Name of Federal Agency, 3 Digit Agency Code, and Address:
3. Local Office/Call Center ID: 4. Date of Request: 5. Date claim taken: 6. Effective Date of Claim:
7. Name (Last, First, Middle Initial)	8. Social Security Number
Complete and Return Within 4 Workdays
9. Location of Official Duty Station. If outside U.S., enter Country: _____________________________ 10. Did this person perform Federal Civilian Service, as defined for UCFE purposes, for your agency at any time on or after the base period begin date shown in Item 11a below? Yes No If No, Complete Items a – e below. a. Under what legal authority was the individual hired?__________________________________ b. What funding Source was used for salary payments? c. Were payroll deductions made for Federal and State taxes? Yes No d. Was Employee eligible for: (1) Annual and Sick leave? __Yes __No (2) Health and Life insurance? __Yes __No (3) Civil Service or FERS retirement? __Yes __No e. Did the Federal agency provide direction and control? Yes __No
11. Are base period wages provided electronically? __Yes __No If “Yes,” go to Item 12. If “no,” report all Wages from base period begin date to separation date. a. Base period beginning date_________ b. Report wages for quarters ending after date in “a” above. # of Weeks # of Hours Qtr. Ending Worked Worked Gross Wages _________ ____ _____ $_______ _________ ____ _____ $_______ _________ ____ _____ $_______ _________ _ ___ _____ $______ _________ ____ _____ $_______ _________ ____ _____ $_______ _________ ____ _____ $______ _________ ____ _____ $______ _________ ____ _____ $_______	12. Separation, Lump Sum Annual Leave, and Severance Pay Information a. Did this person receive payment for annual leave on or after the date of separation? __Yes __No If ,”Yes” or if currently entitled to such a payment, enter below: Amt of payment : $_______ Date of payment: __/__/__ Number of days of Leave: ___ b. Date of Separation __/__/__ c. Reason for separation: ___________ __________________________________________________________________________________________________ _________________________________________________ d. Did this person receive or is he/she entitled to receive severance pay provided by Federal law or agency employee agreement? __Yes __No If “yes,” complete the following information: Total Amount: $_________ Beginning date: ___/___/____Ending Date: ___/___/____
Print Name_________________________________ Signature______________________________ ETA- 931 (Revised 1/2003)	Title___________________________________________ Telephone Number (_____) ___________________ Date____/___/____

OMB No.: 1205-0179 OMB Expiration Date: 08/31/2012 Estimated Average Response Time: 5 Minutes
O M B Burden Statement: These reporting instructions have been approved under the Paperwork reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a valid OMB control number. Public reporting burden for this collection of information includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Submission is required to obtain or retain benefits under SSA 303(a)(6). Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workforce Security, Room S-4231, 200 Constitution Ave., NW, Washington, DC, 20210.

Important Notice

If a completed Form ETA-931 is not received by the 12^th calendar day from the “date of request,” the State agency is authorized by the Department of Labor’s Regulation, published at 20 CFR 609.6(e)(2), to pay benefits to the ex-federal civilian employee based on his/her affidavit. Any benefit payments made to the claimant will be charged to the Federal employing agency(ies) in accordance with Section 1023, PL 96-499, Omnibus Reconciliation Act of 1980 (94 Stat. 2599).

INSTRUCTIONS TO FEDERAL AGENCY

As an alternative to completing this form, attaching a computer printout that contains all of the information requested is acceptable if the layout of the print out is cleared with the U.S. Department of Labor, Washington, DC 20210.

Item 9. Enter the name of the state where the ex-federal civilian employee’s official duty station is located. If it is outside of the U.S., enter the name of the country.

Item 10. If the federal agency’s response is “No” to this question, provide the information requested in questions 10 a - e.

Item 11. The state agency will provide the beginning date of the base period for the unemployment compensation claim filed by the ex-federal civilian employee. All employment and wages from the base period beginning date through the date of separation are reportable in response to this request. Enter the number of weeks worked, number of hours worked and gross wages for the current calendar quarter and all other calendar quarters ending after the base period begin date. Include as wages the amount of any lump sum annual leave payment. Do not include severance pay as wages (Refer to 5 USC 5595).

Item 12. Agency findings are available from SF 50. If payroll office records are incomplete or inadequate, or if information on SF-50 is not sufficient, check with personnel for additional information and add as part of separation information.

Signature of Official. Form is not complete unless it (or attached computer printout) is signed and dated; also enter signer’s title and telephone number.

ETA 931 (Revised 1/2003)

(STATE AGENCY IDENTIFICATION) REQUEST FOR SEPARATION INFORMATION - ADDITIONAL CLAIM
1. State Agency Address:	2. Federal Agency Name, 3 Digit Agency Code, and Address:
3. Local Office/Call Center:	4. Date of Request:	5. Effective Date:
6. Claimant’s Name (Last, First, Middle Initial)	7. Social Security Number
Federal Agency Response B Complete and Return Within 4 Workdays
8. Separation, Lump Sum Annual Leave, and Severance Pay Information a. Date of Separation ____/____/_______ b. Reason for separation:______________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ c. Did this person receive payment for annual leave on or after the effective date of claim shown in item 5? __Yes __No If “Yes”, or if currently entitled to such a payment, complete the following information: Amount of payment: $___________ Date of payment: ____/____/_______ Number of days of Leave: ______ d. Did this person receive or is he/she entitled to receive severance pay provided by Federal law or agency employee agreement? __Yes __No If “yes,” complete the following information: Total Amount of payment: $___________ Beginning date: ____/____/_______ Ending Date: _____/____/________
9. Signature of Official _______________________________________________________ Title: __________________________________ Print Name: _____________________________________________Telephone: ( )___________________Date____/____/_________ ETA-931A (Revised 1/2003)

OMB No.: 1205-0179 OMB Expiration Date: 08/31/2012 Estimated Average Response Time: 5 Minutes
O M B Burden Statement: These reporting instructions have been approved under the Paperwork reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a valid OMB control number. Public reporting burden for this collection of information includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Submission is required to obtain or retain benefits under SSA 303(a)(6). Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workforce Security, Room S-4231, 200 Constitution Ave., NW, Washington, DC, 20210.

(STATE AGENCY IDENTIFICATION) REQUEST FOR ADDITIONAL INFORMATION
1. State Agency Address:	2. Federal Agency Name, 3 Digit Agency Code, and Address:
3. Local Office/Call Center ID: 4. Date of Request: 5. Effective Date: 6. Separation Date:
7. Claimant=s Name (Last, First, Middle Initial)	8. Social Security Number
9. State Agency Statement or Questions of Federal Agency: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
10. Federal Agency Response: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
11. Signature of Official ________________________________________ Title: _____________________________ Print Name: ________________________________ Telephone: (____)___________Date:_____/____/________ ETA-934 (Revised 1/2003)

OMB No.: 1205-0179 OMB Expiration Date: 08/31/2012 Estimated Average Response Time: 4 Minutes
O M B Burden Statement: These reporting instructions have been approved under the Paperwork reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a valid OMB control number. Public reporting burden for this collection of information includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Submission is required to obtain or retain benefits under SSA 303(a)(6). Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workforce Security, Room S-4231, 200 Constitution Ave., NW, Washington, DC, 20210.

OMB No.: 1205-0179 OMB Expiration Date: 08/31/2012 Estimated Average Response Time: 9 Minutes
O M B Burden Statement: These reporting instructions have been approved under the Paperwork reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a valid OMB control number. Public reporting burden for this collection of information includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Submission is required to obtain or retain benefits under SSA 303(a)(6). Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workforce Security, Room S-4231, 200 Constitution Ave., NW, Washington, DC, 20210.