934 Eta 934

(STATE AGENCY IDENTIFICATION)
REQUEST FOR ADDITIONAL INFORMATION

1. State Agency Address:

3. Local Office/Call Center ID:

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

4. Date of Request:

7. Claimant=s Name (Last, First, Middle Initial)

8.

5. Effective Date:

6. Separation Date:

Social Security Number

9. State Agency Statement or Questions of Federal Agency:
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10. Federal Agency Response:
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11.

Signature of Official ________________________________________ Title: _____________________________
Print Name: ________________________________ Telephone: (____)___________Date:_____/____/________

ETA-934 (Revised 1/2003)
OMB No.: 1205-0179
OMB Expiration Date: XX/XX/XXXX
Estimated Average Response Time: 4 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 obtain or retain benefits under SSA 303(a)(6). Send
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