931a Eta 931a

(STATE AGENCY IDENTIFICATION)

REQUEST FOR SEPARATION INFORMATION - ADDITIONAL CLAIM
1.

2. Federal Agency Name, 3 Digit Agency Code, and Address:

State Agency Address:

5. Effective Date:

3. Local Office/Call Center:

4. Date of Request:

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:______________________________________________________________________________
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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)
0MB No.: 1205-0179

0MB Expiration Date: XX/XX/XXXX

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 0MB control number. Publlc 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