STATE OF MICHIGAN

UIA 1713 C/E Authorized By

(Rev. 02-21) DEPARTMENT OF LABOR AND ECONOMIC OPPORTUNITY MCL 421.1 et seq.
UNEMPLOYMENT INSURANCE AGENCY
GRETCHEN WHITMER
GOVERNOR
SUSAN R. CORBIN
DIRECTOR
l
Sent via Go Green

TOMMY HARRIS Mail Date: May 24, 2022

606 BENTON ST Letter ID: L0124335713
DETROIT MI 48201-2126
CLM: CA9804830
Name: TOMMY HARRIS

Request for Information

Employer Name: ** No Employer Selected **
Social Security Number: ###-##-3138
Benefit Year Begin: May 8, 2022 Case Number: 41820071
A question of eligibility and/or qualification has been raised on a claim in which you are an interested party.
Respond to the questions on the reverse side of this form and keep a copy for your records. Return the completed
form to Unemployment Insurance (UI) by June 03, 2022. Failure to respond to this request for information
will result in a determination based on available information.

How to Respond
Submit copies (not the originals) of any records which you believe support your position, such as pay stubs, layoff
slip, federal income tax form, W-2, etc. If you require additional space, attach additional pages(s). Include your
name, Claim ID and Letter ID as shown above, on all documents that you submit.

You can respond online, by mail or fax. To submit your response through your MiWAM account, go to
www.michigan.gov/uia and select "Additional fact finding is required for your claim." If you do not have an existing
MiWAM account, you can create an account by selecting "Register as a New User", and follow the prompts. To
respond by mail, return the completed form along with a copy of any additional documents to Unemployment
Insurance Agency, P.O. Box 169, Grand Rapids, MI 49501-0169 or fax to (517) 636-0427.

Penalties
It is against state law to intentionally make false statements or conceal material information to gain or avoid the
payment of benefits. You may have to repay up to 1.5 times the amount of benefits received. Benefits will be
stopped, and any remaining benefits will be lost. You may also be subject to criminal prosecution. If prosecuted,
you may be required to pay court costs and fines, face jail time, perform community service or any combination of
these.

If your address changes it is important to update it with Unemployment Insurance.

If you have questions, contact UIA Customer Service at 1-866-500-0017. TTY customers use 1-866-366-0004.

1 UIA is an Equal Opportunity Employer/Program.

l Auxiliary aids, services and other reasonable

accommodations are available upon request to
individuals with disabilities.
UIA 1713 C/E Letter ID: L0124335713
(Rev. 02-21)

Additional information is necessary regarding Unaware of Requirements to Register.

False

You were required to register for work with Michigan Works! MiTalent Connect by 5/23/2022.

Did you register for work with Michigan Works?

Yes No

What date did you register?

____________________

Did you receive verification from Michigan Works that you registered?
Yes No

Please provide a copy of this verification

Why were you unable to register at Michigan Works! MiTalent Connect by the above date?
Attending School/Training
Childcare Issues
Ill, Injured, Hospitalized
Incarceration (Jail /Prison)
Lack of Transportation
Michigan Works! MITalent Connect System Not Available
Not Aware of Requirement
Out of Town/Vacation
Personal Reasons

Certification: I certify that the information I have reported is true and correct. I understand that if I intentionally
make a false statement, misrepresent facts or conceal material information to reduce or prevent benefits, I may be
required to repay benefits, charged damages and could be subject to criminal prosecution.
______________________________________________ _____________________ ______________________________
Signature Date Telephone Number
_______________________________________________ ____________________________________________________________
Print Name Title

1
UIA is an Equal Opportunity Employer/Program.
Auxiliary aids, services and other reasonable

l accommodations are available upon request to

individuals with disabilities.
UIA 1713 C/E Letter ID: L0124335713
(Rev. 02-21)

1 UIA is an Equal Opportunity Employer/Program.

l Auxiliary aids, services and other reasonable

accommodations are available upon request to
individuals with disabilities.
UIA 1713 C/E Letter ID: L0124335713
(Rev. 02-21)

English
IMPORTANT! This document(s) contains important information about your unemployment compensation rights,
responsibilities and/or benefits. It is critical that you understand the information in this document.

IMMEDIATELY: If needed, call 1-866-500-0017 for assistance in the translation and understanding of the information
in the document(s) you have received.

Spanish
¡IMPORTANTE! Este documento (s) contiene información importante sobre sus derechos, responsabilidades y / o
beneficios de compensación de desempleo. Es fundamental que comprenda la información de este documento.

INMEDIATAMENTE: Si es necesario, llame al 1-866-500-0017 para obtener ayuda en la traducción y

comprensión de la información en el (los) documento (s) que ha recibido.

Arabic

Albanian
• E RËNDËSISHME! Ky dokument përmban informacione të rëndësishme për të drejtat, përgjegjësitë dhe / ose
përfitimet e kompensimit të papunësisë. Është e rëndësishme që ju të kuptoni informacionin në këtë dokument.
• MENJËHERË: Nëse është e nevojshme, telefononi 1-866-500-0017 për ndihmë në përkthimin dhe kuptimin
e informacionit në dokumentet që keni marrë.