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VACATION SHUTDOWN STATE OF CONNECTICUT DEPARTMENT OF LABOR EMPLOYMENT SECURITY DIVISION

NEW CLAIM
FOR UNEMPLOYMENT Print your Social Security No.
COMPENSATION BENEFITS COMPLETE THIS here. (Be sure to copy from
your Soc. Sec. Card)
Form UC-62V (Rev 6/07) FORM IN PENCIL
(One Number Per Block)
NAME (Please Print) First (Middle Init.) (Last) DATE OF BIRTH SEX
I Mo Day Year M F

CLAIMANT MAILING ADDRESS (No. & Street) or (P.O. Box Number) MARITAL STATUS
Sing. Marr. Wid. Sep. Div.
INFORMATION 1. 2. 3. 4. 5.
CITY (DO NOT ABBREVIATE) STATE ZIP Town you live in if different from mailing address TELEPHONE NO.

Complete form by YES NO YES NO


ARE YOU A U.S. CITIZEN? If NO, I certify that I am in satisfactory IN THE LAST 24 MONTHS HAVE YOU:
Friday of the first alien status. Attach copy of front and back of card and write alien
week which you number here.
Worked in another state? If yes, what state?
claim benefits and ARE YOU RECEIVING SOCIAL SECURITY BENEFITS? Worked for a federal agency?
return to: ARE YOU RECEIVING A PENSION OR OTHER RETIREMENT
BENEFITS?
Served in the Armed Forces?
Claims Exam Unit
ARE YOU ATTENDING SCHOOL OR TRAINING?
Worked for an educational institution?
Dept of Labor
200 Folly Brook Blvd Been a corporate officer, self-employed, owner of a business?
ARE YOU A CONSTRUCTION WORKER?
Wethersfield, CT
06109 Have you worked (either full or part-time) for any OTHER employer in Worked under another name? (If “Yes,” print name here.)
the last 3 months? (if YES, complete Section VIII on back)

TAX
I ELECT TO HAVE FEDERAL (10%) AND CT STATE (3%) INCOME TAX WITHHELD FROM MY UNEMPLOYMENT BENEFITS YES NO
WITHHOLDING
I hereby serve notice of intent to apply for unemployment benefits. I request and agree to accept the establishment of a Benefit Year, if none is in effect. I authorize
the release to the Department of Labor of such wage and other information that may be required to determine my eligibility for Unemployment Compensation Benefits. See
I certify that the information provided on both the front and back of this form is true and correct. I understand that a false statement or failure to disclose material facts Disclosure
AUTHORIZATION to obtain benefits is a violation of the law. Information
on reverse
Instructions SIGNED (Claimant) DATE
of form

COMPLETE THE OTHER SIDE IF YOU WISH TO FILE FOR DEPENDENCY ALLOWANCE OR IF YOU WORKED FOR A FEDERAL OR STATE AGENCY
Effective Date Date Reported
Tax With. S.A.C. No. Spouse RNO Occ. Code
II. Mo. Day Year Mo. Day Year Dep.
YES NO Allow. Yes No
FOR Branch of Military Service UCX Employer Number Mass Layoff UC-893 ES-931 UC-1070 1B-4
FFR Issue No. PRIM.
01. Vol. Leaving
OFFICE 02. Vol. Retirement 1. X 2. 3. 4. 5.
03. Student Quit PENSIONING EMPLOYER PAYMENT ALLOC: Type Code: 1. Sev. 2. Vac. 3. Hol. 4. Other
04. Willful misconduct or felonious
USE Name AMOUNTS
conduct Type Allocated to
05. Refusal of Rehire Code Stat Non stat Week Ending
06. Refusal of Work SEC.
ONLY 07. Able Available Street Mo. Day Year
08. Reasonable Eff.
09. Sec. Ben. Year
(5 X WBR or $300) City
10. Disq. Income
11. Deduct. Income (pot. earn, etc.)
12. Student Avail. State
13. Invalid Filing
15. Labor Dispute SEC. EMP FFR
16. FSC. TRA Yes ⏐ No DATE UC-952 Mo Day Year
20. Monetary MAILED
(inc. dep. allow)
PROGRAM 21. 10 x WBR (quit) Reg. # C.S.R. J.C. Number
22. 10 x WBR (discharge)
23. 40 x WBR (vol. Ret.) 0
UV 24. 5 x WBR or $300 (2nd ben. yr.)
25. Sec. 31-227(d)(e)(f) REMARKS
31. 6 x WBR (Refusal of Rehire/Work)
32. 4 x 4 (Requal wage FSC, TRA)

CONN. REGISTRATION NO. 3. COMPANY NAME, STREET, TOWN, STATE AND ZIP CODE 4. EMPLOYEE’S NAME
III. ADDRESS TO WHICH NOTICE OF FACT FINDING
HEARING WILL BE SENT.

EMPLOYER 1. NCCI CODE/CLOCK NUMBER 5. EMPLOYEE’S SOCIAL SECURITY NO.


INFORMATION
7. LENGTH OF MOST RECENT 6. WAGES FOR LAST WEEK OF WORK FROM SUNDAY TO
(TO BE PERIOD OF EMPLOYMENT DATE LAST WORKED (If less than full week)
COMPLETED BY NO. OF HOURS WAGES
EMPLOYER) YRS MOS DAYS
8. DATE LAST WORKED 9. RETURN TO WORK DATE 10. Will any payment be made or has any No
payment been made which is not
Use this form if wages for work actually performed? Yes
there is a definite 12. TYPE OF PAYMENT (If yes above) 13. LAST DATE COVERED BY PAYMENT
return to work date 1. REASON FOR UNEMPLOYMENT 1. Severance 2. Vacation
(#9) that is 6 weeks 3. Holiday 4. Other
or less from the date 1. LACK OF WORK – TEMPORARY COMPANY SHUTDOWN Type No. of Hours/Days AMOUNT DATES COVERED
last worked (#8). Covered
Also, there should be
14. I certify that the information in this notice is true and correct
no other issues
involved. Otherwise,
please use the
Separation Packet - SIGNATURE AND TITLE OF OFFICIAL DATE Office Use
Form UC-62T. ( )
Claimant Stmt.

TELEPHONE NUMBER
Yes
Information concerning an individual’s unemployment compensation claim AUTHORITY: The Connecticut State Labor Department, Employment Security
IV may be disclosed, under certain circumstances, to other governmental Division is empowered to solicit this information under the authority of Conn.
agencies pursuant to Title XI of the Social Security Act as amended by Statute, Sections 31-222 and 31-254 as supplemented by Section 31-222-8 of the
Public Law 98-369 (42 U.S.C. 503 (F) ). Unemployment Compensation Regulations.
It is possible that information concerning your filing history could be EFFECTS OF NON-DISCLOSURE: Disclosure of the requested information is
accessed by other state, municipal, or federal agencies involved in an voluntary; however, failure to disclose this information will preclude processing of
income and eligibility verification system. your claim.
DISCLOSURE USES: The information required will be used by the Employment Security PURPOSE: The information requested by this form is considered relevant and
INFORMATION Division to access wage records and process your application or claim. necessary to determine entitlement of the services and benefits for which you
have applied.
You may claim a dependency allowance for a non-working spouse (as defined by regulation) who lives with you in the same household.
V
Enter your spouse’s name only if you checked box 1, 2 or 3.
I certify that my spouse, here named, lives with me in the same household, is First Middle Init. Last
currently unemployed, and: (CHECK ONE)
SPOUSE
DEPENDENCY 1. Has not worked in the last three months 3. is pregnant Spouse’s Social Security No. Is your spouse filing for Yes No
ALLOWANCE Unemployment Compensation?
PROGRAM 2. Has a mental or physical disability that is expected to prevent
employment and to continue for a long or indefinite period of time.

VI CAUTION: Complete this section ONLY if you wish to claim an allowance and are the whole or main support of the children.
ALL QUESTIONS IN THIS SECTION MUST BE ANSWERED IN ORDER TO DETERMINE ELIGIBILITY FOR DEPENDENCY ALLOWANCE.
If children do not live with you, you MUST present proof of support (cancelled checks, receipts, etc.) for the last three months.
CHILD I certify that I am the whole or main support of my children or stepchildren, or children for whom I have assumed parental
DEPENDENCY responsibility who:
ALLOWANCE 1. are under 18 years of age, or
PROGRAM 2. are under 21 and a full-time student,(s), or
3. have a mental or physical disability.
Town or City and State where Lives with IF 18 OR OVER
ENTER FIRST AND LAST NAME OF YOUR
Relationship Birth is recorded Date of Birth you Circle Handicapped Name of School Attending Dates of Attendance
DEPENDENT CHILDREN One Circle One
Mo day yr.
YES NO YES NO

Mo day yr.
YES NO YES NO

Mo day yr.
YES NO YES NO

Mo day yr.
YES NO YES NO

Mo day yr.
YES NO YES NO

1. What is your weekly income? _____________________________________________ 2. What is your spouse’s weekly income? _____________________________________

3. Do you receive any contributions from any other source for child 4. If the child does not live with you, how much do you contribute to
support? Yes No support? $________. What is the amount of contribution from
If yes, how much? $________ Child’s Name ______________________________ other sources? $_________.
MY SIGNATURE ON THE FACE OF THIS FORM CERTIFIES THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT AND THAT I AM THE WHOLE OR MAIN
SUPPORT OF THE CHILDREN LISTED ABOVE. I UNDERSTAND THAT MY DEPENDENCY ALLOWANCE CLAIM MAY BE AUDITED AND I MAY BE REQUIRED TO
ESTABLISH PROOF OF ENTITLEMENT.
VII 3. ENTER DATES WORKED TOTAL NUMBER TOTAL GROSS
DURING EACH WEEK SINCE OF HOURS EARNINGS
1. Did you work, do you expect to work, or was work available to you DAY OF SEPARATION WORKED
from any employer other than the one listed in Section III on the
front side of this form? YES No WEEK 1
(Sun. – Sat.)

If yes, complete items 2 and 3. If you do not know your total gross WEEK 2
earnings for item 3, check here: (Sun. – Sat.)

WEEKLY 2. EMPLOYER’S NAME ___________________________________________ WEEK 3


BENEFIT (Sun. – Sat.)
EMPLOYER’S ADDRESS ___________________________________________
CLAIM ___________________________________________
WEEK 4
(Sun. – Sat.)

4. I certify that I have been or will be temporarily unemployed during the period of time listed in Section III of this application. All earnings or wages
which I have received or expect to receive from this employer are reported in Section III. Wages or earnings received or to be received from any
other employer are indicated in the above Section. I understand that if I return to work prior to the date listed on this form or if I suffer an illness or
injury that renders me unavailable for work, I must notify the Unemployment Compensation Department. I realize that the law provides penalties
for false statements made to obtain benefits.

SIGNED (Claimant) __________________________________________________________________________________ DATE____________________________________

VIII EMPLOYER NAME REASON FOR SEPARATION


OR STILL EMPLOYED 10X MET? YES NO (JOB CENTER USE)

Per Claimant
OTHER ADDRESS LAST DAY WORKED

EMPLOYMENT $___________________ From _________________


EARNINGS EMPLOYER
IN EMPLOYER NAME REASON FOR SEPARATION
PAST 3 OR STILL EMPLOYED 10X MET? YES NO
MONTHS Per Claimant
ADDRESS LAST DAY WORKED
$____________________From ________________
EARNINGS EMPLOYER

Clear
INSTRUCTIONS FOR FILING A TEMPORARY LAYOFF CLAIM
(VACATION SHUTDOWN)

For Claim filing purposes, you are on a temporary layoff only if you have a definite return to work date that is six (6) weeks or less from your
last day worked. This date is in the “Employer Information” Section III (#9) on form UC-62V (Vacation Shutdown New Claim). If your
employer gave you form UC61 (pink slip), this date is in the “Return to Work” box.

If you are on a temporary layoff as defined above, follow the directions on this form. If not, you must call in your claim using the Automated
“Dial to File” System. See the reverse side of this form for the telephone number that is within your calling area.

● If your employer gave you a form UC-62V (yellow claim form) with Section III (“EMPLOYER INFORMATION”)
completed, follow the instructions listed below.

● If your employer gave you a completed form UC61 (pink slip), take a blank form UC-62V (yellow form). Follow the
instructions listed below for completing this form. You must attach the UC61 (pink slip) to the completed UC-62V.

Completed UC-62V forms should be mailed to the following address by the end of the first full week you are out of
work or unemployed.

DEPARTMENT OF LABOR
CLAIMS EXAMINATION UNIT
200 FOLLY BROOK BOULEVARD
WETHERSFIELD, CT 06109

Follow these instructions carefully to avoid delays in the processing of your claim:

Complete Section I – front side of Form UC-62V (“CLAIMANT INFORMATION”)

Enter your social security number, complete all information and answer all questions. Please print your name and
mailing address carefully. This is the name and address that will be used on your checks and correspondence.
SECTION I MUST BE SIGNED.

● If you are not a U.S. citizen attach a copy of your valid alien registration identification – front and back sides – to form UC-62V. Also
write the alien registration number in the appropriate space in Section I of the UC-62V.

● Generally, you are considered a “Construction Worker” only if the majority of hours in your most recent pay period before this
shutdown period were spent performing construction work.

● You may elect to have both Federal and CT State Income Tax withheld from your unemployment benefits. If you choose to do this,
Federal tax at 10% and State tax at 3% will be withheld.

Complete Section VII – back side of Form UC62-V (“WEEKLY BENEFIT CLAIM”)

● This section is a certification for weekly benefits during the shutdown period. If you are working either full or part-time for another
employer during the shutdown period, answer yes to question one and complete questions two and three. If you are not working for
another employer during shutdown, answer no to question one. SECTION VII MUST BE SIGNED.
SEE REVERSE SIDE FOR IMPORTANT ADDITIONAL FILING INFORMATION

Section V- back side of Form UC-62V (“SPOUSE DEPENDENCY ALLOWANCE PROGRAM”)

● Complete this section only if you are claiming a dependency allowance for a non-working spouse, who lives with
you in the same household. All information must be complete in order for a determination of eligibility to be made
for a dependency allowance.

Section VI – back side of Form UC62-V (“CHILD DEPENDENCY ALLOWANCE PROGRAM”)

● Complete this section only if you wish to claim an allowance and are the main support of the children. All
information must be complete in order for a determination of eligibility to be made for a dependency allowance.

Section VIII – back side of Form UC62-V (“OTHER EMPLOYMENT IN THE PAST 3 MONTHS”)

● This section must be completed if you have had any other employment in the past three (3) months, whether
full or part-time. If you are still employed by this other employer, be sure to indicate that you are still employed.
Otherwise, give the reason for separation. Please print the employer’s name and address.

If you have questions concerning your claim, please call the telephone number listed that is within your
calling area.

CALLING AREA # TO CALL CALLING AREA # TO CALL


Ansonia (203) 230-4939 Meriden (860) 344-2993
Bridgeport* (203) 579-6291 Middletown (860) 344-2993
Bristol (860) 566-5790 New Britain (860) 566-5790
Danbury (203) 797-4150 New London (860) 443-2041
Danielson* (860) 423-2521 Norwich (860) 443-2041
Enfield* (860) 566-5790 Stamford (203) 348-2696
Hamden (203) 230-4939 Torrington* (860) 482-5581
Hartford (860) 566-5790 Waterbury (203) 596-4140
Manchester (860) 566-6790 Willimantic (860) 423-2521

*If you live in the Kent, North Thompson, Salisbury, Sharon, Stafford Springs, Westport, or Wilton
exchange, you may use the following toll free number.

1-800-354-3305

This number is NOT accessible statewide. It is only for the seven towns listed above.

TDD/TTY Users CALL 1-800-842-9710


Completed UC-62V forms (Vacation Shutdown New Claim) can be mailed to the address on page one of this
form, or, left in the basket labeled “completed shutdown forms” at the Greeters’, or
Receptionists’ Desk at the local Department of Labor office.

WHAT TO EXPECT AFTER YOU SUBMIT YOUR CLAIM

When should you expect a check?

You should receive your first check within 3 weeks of the date you submit your claim. Note: excessive
claim activity during the winter months may delay payment slightly.

Once you receive payment for your first week, each additional week should be paid by the end of the
following week (e.g., week ending January 12th should be paid by January 19th ).

You may be contacted for additional information if:

- You worked in another state within the last two years


- You served in the military in the last two years
- You worked for a federal agency in the last two years
- You are receiving a pension
- You separated from another employer in the last 3 months

Payment may be delayed if:

- You have a second job and you did not provide earnings information for each week that you are laid off
from your primary job (in section VII)
- You were denied benefits on a previous claim and have fulfilled requalification requirements that need
to be verified. If so, contact the Department of Labor to request that this be done.
- You worked part of a week and your earnings for that week were not provided.

Questions about payment:

If you have a question regarding payment, contact the automated system using the number in your
calling area on the previous page. After you place the call, follow the instructions for Continued Claim
inquiry (Option #2)