Form ETA 843 ETA 843 Request for Military Documentation for UCX

(State Agency) Request for Military Document/Information For Unemployment Compensation Purposes—UCX					For Federal Agency Use Only
					File Reference No.
					Local Office
					Date of Request
To: ╔ ╗ ╚ ╝
Section I. Identification Data
1. Name (Last, First, Middle)	2. Social Security Number			3. Date of Birth
4. Service Branch	5. Entry Date			6. Separation Date
7. Place Separated			8. Ex-Serviceperson’s Last Pay Grade
9. Last Duty Assignment/Command			10. Indicate if Ex-Serviceperson Was in—  Military Reserve  National Guard
11. If 10 is marked, complete a through c.
a. Reserve Branch	b. Beginning Date			c. Ending Date
12. Other Data (Identify)			13. Present Address
Section II. Document/Information Requested
MILITARTY SERVICE OR RECORDS CENTER: Either DD For 214 or military information, as indicated below, is necessary to determine Federal military service in connection with a claim for unemployment compensation for ex-service personnel (5 U.S.C. 8521 et seq). Complete Section III of this form.
(“X” appropriate box(es))  14. DD Form 214 is needed because:  a. Form was not issued at time of separation; or  b. Form was lost since issued. Forward DD Form 214 to the address of the State employment security agency shown on the reverse.  15. Accrued days paid (number)			 16. Other (Identify; attach copy of DD Form 214)
Release Authorization: Please furnish the indicated document/ information to the State agency shown on the reverse of this form.		Ex-Serviceperson’s Signature				Date
Section III. Federal Agency Reply
17. (See item 14 above) “X” one only.	a.  Copy of DD Form is attached			b.  Other (Explain)`
18. (See item 15 above) Accrued Leave Days Paid (Number)			19. Other Data (as identified in item 16 above.
20. Signature of Authentication Official and Title			21. Date (Month, Day, Year)

OMB No.: 1205-0176 OMB Expiration Date: 03/31/2016 Average Estimated 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 retain or obtain 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.