Form ETA 841 ETA 841 Request for Determination of Federal Military Service an

(State Agency) Request for Determination of Federal Military Service and Wages—UCX

Local Office

Date New Claim Filed

1. Name (Last, First, Middle)

2. Social Security Number(s)

3. Have you filed an unemployment compensation claim under any State or Federal law (UI, UCFE, UCX) since your most recent separation from active military service? (NOTE: Correct answer may be “YES” if you filed a claim even if you did not receive any benefit payments)

YES 

NO 

4. If “YES”, When?

5. Where?

ACTIVE MILITARY SERVICE: (List all service, most recent first, any day of which was during the base or lag period.)

6. Service Branch

7. Character of Service

8. Are you a Military Retiree?

9. Entry Date

10. Separation Date

11. Days Lost (Dates)

12. No. Days Accrued Leave

YES 

NO 

13. Ending date of most recent accrued leave period.

14. Ex-Service Person’s Last Pay Grade

E-

W-

O-

14. HAVE YOU APPLIED FOR, OR ARE YOU RECEIVING, FROM THE VETERAN’S ADMINISTRATION A substance allowance for vocational rehabilitation training (38 U.S.C, ch, 31)? A war orphan’s widow’s educational assistance allowance (38 U.S.C. ch 35)?

YES 

NO 





CERTIFICATION: I, the claimant, hereby request a determination of Federal military service under the Federal UCX law (5 U.S.C. 8501 et seq.) with respect to all active military service performed with the last 18 months. I certify that the information shown above is, to the best of my knowledge, correct and complete. I am aware of the penalties for making false statements.

16. Claimant’s Signature

17. Date

18. Interviewer’s Signature

19. Date

20. STATE AGENCY USE ONLY: If answer to item 3 is “YES,” was a benefit year established?  Yes  No

21. Ex-Serviceperson’s Wage Rate (From Federal Schedule; 20 CFR part 614)

a. Per Month $

b. Per day $

22. Ex-Serviceperson’s Federal Military Service and Wages

a. Base Period*

b. Lag Period*

Quarter Ending

Federal Military Service

Federal Military Wages *

Quarter Ending

Federal Military Service

Federal Military Wages *

Months

Days

Months

Days

Total UCX Wages in Base Period

Total UCX Wages in Lag Period

* NOTE: Federal military wages equal Federal military service multiplied by Item 21

23. Date UCX Inquiry Made to LCCC

OMB No.: 1205-0176 OMB Expiration Date: 03/31/2016 Average Estimated Response Time: 1 Minute

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.

24. If you believe any military service information on which this determination is based is incorrect or substantially incomplete, you may request reconsideration as follows:

    1. Information obtained from your separation papers:
       Send a request directly to your branch of service and notify your local unemployment compensation claims office.

    2. Information supplied by the Veteran’s Administration:
       File a request in your local unemployment compensation claims office for transmittal to the Veteran’s Administration.

These actions must take place by . File an appeal with such period to protect your appeal rights while your request under (a) or (b) is being considered. This office will assist you, if needed. If you appeal, you should continue to file claims until a final decision is rendered or you return to work.