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UC-1120A

(Rev. 8/03)
STATE OF CONNECTICUT
DEPARTMENT OF LABOR
EMPLOYMENT SECURITY DIVISION
CERTIFICATION OF EARNINGS

Employer Name: Date:

Employer Address: Claimant Name:


S.S. #
DEAR EMPLOYER ,

THE DEPARTMENT OF LABOR NEEDS INFORMATI ON FOR A ROUTINE AUDIT OF THE ABOVE MENTIONED CLAIMANT. IN ORDER FOR OUR DEPARTMENT TO
COMPLETE OUR AUDIT, YOU MUST PROVIDE THE WEEKLY WAGE INFORMATION REQUESTED BELOW AND RETURN IT WITHIN FOURTEEN (14) DAYS OF THE
DATE OF THIS LETTER , USING THE ENCLOSED ENVELOPE. Y OU MAY FAX YOUR COMPLETED REPLY TO (860) 263-6343.

UNEMPLOYMENT COMPENSATION IS PAID ON A CALENDAR WEEK BASIS, BEGINNING ON SUNDAY AND ENDING ON SATURDAY NIGHT. Y OU MUST USE A
CALENDAR WEEK, NOT A PAYROLL WEEK TO REPORT GROSS WAGES IN WHICH THOSE EARNINGS WERE EARNED . IF THE ABOVE REFERENCED EMPLOYEE
DID NOT WORK DURING THE WEEKS LISTED , WRITE ‘NONE’ ACROSS THE PAGE, COMPLETE THE LOWER PORTION AND RETURN THE FORM. PLEASE CALL
(860) 263-6335 IF YOU NEED ASSISTANCE IN THE COMPLETION OF THIS FORM.

From To Gross Total From To Gross Total


Actual Compensated Actual Compensated
(Sunday) (Saturday) Earnings Hours (Sunday) (Saturday) Earnings Hours

ALL INFORMATION FURNISHED IN THIS CERTIFICATION MUST BE CORRECT BECAUSE IT MAY BE USED FOR PROSECUTION PURPOSES. YOU MAY BE

CALLED INTO COURT TO CONFIRM THE PAYMENTS. THIS REPORT MUST BE SIGNED AND DATED BY AN AUTHORIZED OFFICIAL.

FAILURE TO RESPOND TO THIS CERTIFICATE WILL RESULT IN A SUBPOENA BEING ISSUED IN ACCORDANCE WITH THE PROVISIONS OF SECTION 31-

245 OF THE GENERAL STATUTES.

Date started Date left Reason for leaving


I Certify that the information given above Is correct to the best of my knowledge

Date Authorized Official Title Phone # Fax#


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