BAM Forms

Benefit Accuracy Measurement Employer Verification Batch Seq Claim Type
Claimant Name:									Claimant SSN:
Employer:							Employer Acct #:		Contact Person:
Employer Address:							Phone:		Fax:
Claimant Hired on:	Separated on:			Last Day Worked:			States worked in:		Other SSN or Name used: while employed in last three years?  Yes  No If Yes, provide it:
Claimant provided I-9 Employment Eligibility Verification Information				 - US Citizen  -Alien Authorized to Work  - Lawful Permanent Resident					Alien #
Payroll: frequency is? Circle answer Daily, Weekly, Biweekly, Semi-Monthly, Monthly, Commission					Pay Period begins on what day of the week? And ends on what day?						Pay Day is on what day?
Recall  Yes  No Date?		Claimant actively employed?  Yes  No				Rate of pay when employed $ Per:			For requalification: total earnings since = $
Type of work (Check all that apply)  Full time  Part Time  Contract worker  Federal  Military  Seasonally
Claimant Job title:			Claimant Job Responsibilities
Circle Separation type: Quit / Fired or Discharged for Misconduct / Permanent layoff –Reduction In Force / Temporary layoff / Still working / Retirement / Discharge - no misconduct (unable to perform) / Other compelling reasons (i.e. move with spouse, family illness)
Explain separations except lack of work/layoff.
If wages were for any time period after last day worked, please complete the following:
TYPE OF PAY					$ AMOUNT			# OF WEEKS		DATES COVERED
Accrued Vacation
Holiday \ Sick
Last Pay Period
Commission \ Bonus
Wages in Lieu of Notice
Severance \ Separation Pay
Pension - Employer contribution plan? Yes or No

BASE PERIOD YEAR – FROM ( / / ) TO ( / / )

	Year/Quarter:			Year/Quarter:
IMPORTANT:	PAY PERIOD			PAY PERIOD
Please enter each pay period end date and	BEGIN AND END DATES	PAYDAY	GROSS PAY	BEGIN AND END DATES	PAYDAY	GROSS PAY
gross pay for
each payday in
the quarter. If
the amounts for
all weeks do not
match the
original amount
reported by you –
please call!
TOTAL AUDITED

A-10

Appendix A

BASE PERIOD YEAR – FROM ( / / ) TO ( / / )

IMPORTANT: Please enter each pay period end date and gross pay for each payday in the quarter. If the amounts for all weeks do not match the original amount reported by you – please call!	Year/Quarter:			Year/Quarter:
	PAY PERIOD BEGIN AND END DATES	PAYDAY	GROSS PAY	PAY PERIOD BEGIN AND END DATES	PAYDAY	GROSS PAY
TOTAL AUDITED

CLAIM BENEFIT YEAR EARNINGS – FROM ( / / ) TO ( / / )

If you hired this person after the “from” date above, was this new hire reported to the New Hire Registry?  Yes  No.

If yes, when and to which state was the new hire reported .

If you did not report this person as a new hire, did you previously employ this person within the past 60 days?  Yes  No.

IMPORTANT: Please enter each pay period end date and gross pay for each payday in the benefit claim period shown above. If the amounts for all weeks do not match the original amount reported by you – please call!	PAY PERIOD BEGIN AND END DATES	PAYDAY	GROSS PAY		PAY PERIOD BEGIN AND END DATES	PAYDAY	GROSS PAY
TOTAL AUDITED
I certify that the above information is correct to the best of my knowledge and belief.
Employer’s signature:				Title:				Date:

Official Use Only

Auditor’s signature:	Phone: Fax:	Date Received:
Form completed:	Employer is:	Batch Seq# Type
Employer is represented by a third party: