PENDING ISSUE - NEW HIRE QUESTIONNAIRE

NMON-111

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The response to Question 1 is required.
The response to Question 7 is required.
The response to Question 8 is required.

Claimant SSN

Claimant Name

The DES needs to confirm your current employment status to determine eligibility for unemployment benefits. No further benefits can be paid until you submit this completed questionnaire. Continue to file your weekly requests for payment while this issue is being investigated.

1.	*	Were you hired by the employer shown above?		Yes No
	a.		If Yes, what date did you or will you start?	/ /
	b.		If No, why did you complete the new hire federal "Employee's Withholding Allowance Certificate" (Form W-4) paperwork?
2.		Are you still employed by this employer?		Yes No
	a.		If No, what date did you last work for this employer?	/ /
	b.		Why are you no longer working for this employer?
3.		Provide employer's telephone number, including area code.		-- Ext.
4.		Did you work for any other employer during the weeks listed below ?		Yes No
	a.		If Yes, Who?
5.		You have filed weekly requests for payment for the weeks below. Report your gross earnings for each of the weeks listed. Wages must be reported for a Sunday-Saturday calendar week.

CWE Date	Wage Amount($)

6.		If you did not accurately report wages when you submitted the weekly requests for payment for any of the weeks shown above, explain why.
7.	*	Do you want to attach any supporting documents to this response?	Yes No
8.	*	I certify the information provided is truthful and correct to the best of my knowledge.

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