Request for Determination of Federal Military Service and Wages-UCX

Unemployment Compensation for Ex-Servicemembers Handbook

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1205-0176 can be found here:

Documents and Forms

Document Name Document Type
Form ETA 841 Request for Determination of Federal Military Service and Wages-UCX Form
ETA 841 Request for Determination of Federal Military Service an ETA 841 Form_FINAL.doc Form

Information Collection (IC) Details

IC Title:	Request for Determination of Federal Military Service and Wages-UCX	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	ETA 841	Request for Determination of Federal Military Service and Wages—UCX	ETA 841 Form_FINAL.doc		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 102,682	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	102,682	102,682
Annual IC Time Burden (Hours)	1,711	1,711
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.