District Office Record of Determinations as to Voluntary Quit

CURRENT
1. SSA No.

DISTRICT OFFICE RECORD OF
DETERMINATIONS AS TO VOLUNTARY QUIT

2. Claimant's Name

3. Information About Leaving Work
a. Date left work:
b. Employer:
c.

Occupation:

Reason for leaving work:
By Claimant:
By Employer (If employer statement not obtained, explain why):

4. Determinations by District Office
a. Leaving was:
1.

Not Voluntary (Provide AIM/FOM reference, explain in full the determination, and go to Item 4.C.):

2.

Voluntary
a.
b.

With Good Cause (Provide AIM/FOM reference, explain, and go to Item 4.B.):
Without Good Cause (Provide AIM/FOM reference, explain, and go to Item 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.
Information that claimant could receive other benefits (Explain source and show the period):
Other (Explain):
c.

Determined by:
Reviewed by:

_____________

Date:

__________

___________________________________________

Date:

______________________

5. Date disqualification period ended:
6. Are there qualifying railroad wages after voluntary quit?

Yes

No

Determined by: ______________________________________________________

Date: _________________

Reviewed by:

Date:

______________________________________________________

________________

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

UI-33 (12-05)