Weekly Unemployment Benefits Certification Form

Personal Information Full Name Social Security Number Week Ending Date

Certification Questions Were you able and available to work this week?

Yes No

Did you refuse any work offered to you?

Yes No

Did you work or earn any income during this week?

Yes No

If yes, enter the gross amount earned: Did you receive any other type of compensation (vacation, severance, pension)?

Yes No

If yes, explain:

Job Search Activities List job search activities this week:

Certification

I certify that the above information is true and complete.

Signature Date