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DEPARTMENT OF ECONOMIC OPPORTUNITY REEMPLOYMENT ASSISTANCE APPLICATION FOR SERVICES Form ETA-81 (Rev. 03/12) PLEASE PRINT YOUR INFORMATION IN BLUE OR BLACK INK ONLY FOR ALL ITEMS (on both sides of the application) AND SIGN THIS FORM. Complete a Supplement for other employment you have had during the last 18 months. Please mail to the following address: Florida Department of Economic Opportunity, P.O. Box 5350 Tallahassee, FL 32314-5350 1. Name: (First, Middle, Last) *Social Security Number: (see Privacy Act Statement on back of form) — — FOR OFFICE USE ONLY, DO NOT WRITE IN THE GRAY AREA BELOW 1a. Other Names Used During Employment EFF Date M D Y DATE FILED M D Y 2. Local Mailing Address: Street Address: Apt.# CLAIM NEW ADD'L R/O T REQUALIFY City: State: Zip: Residence County: STATUS TYPE: UC X FE CWC EB OTHER 3. Telephone Number: Alternate phone number: ( ) — or ( ) — ISSUE: (check one) UCB-13 MODS STDK METHOD 4. Date of Birth: 5. Sex: 6. Height/Weight NO Month Day Year M YES - enter flag codes F / 1. LOCAL OFFICE FIPS RES. COUNTY WDB 7. (Statistical use only) Are you of Hispanic descent? YES NO 2. Indicate your primary ethnic affiliation: 3. IND W/S ERP MCS White (1) Black or African American (2) American Indian or Alaskan Native (4) 4. Asian (3) Hawaiian or Pacific Islander (5) IB4 STATE/FIPS CODE Information not available (6) 8. Identification (ID): Driver’s License #: _________________________________ State of Issuance: _________________________________ Primary DOT Code: Mo. Exp. Secondary DOT Code: Mo. Exp. State Identification #:________________ State of Issuance:__________________ _____________________________________________________________________ Other ID #: Type of ID: ____________________________________________________________________ 9. Check the number which corresponds to the highest grade you completed: 1. Did not finish High School - Highest grade completed was: 1 2 3 4 5 6 7 8 9 10 11 12 2. High School Diploma or GED 3. AA or Post Secondary Vocational/Technical Certificate of Completion 4. BS/BA 5. MS/MA 6. Doctorate Disaster Date: Announcement Documentation presented: Disaster #: FL TYPE: ________________________________________________________ Secondary DOT Primary DOT Code: Mo Exp. Code: Mo. Exp. ________________________________________________________ 10. Are you handicapped as defined in Section 504 of the Rehabilitation Act of 1973? YES NO Definition: A person is handicapped if he or she has a physical or mental impairment which substantially limits one or more major life activities; has a record of such impairment; or is regarded as having such impairment. NOTE: This information will be used for statistical purposes only; is requested on a voluntary basis; and will be kept confidential. 11. I am a citizen of the United States. YES NO Alien Reg. #: If no, I am authorized to work in this country. YES NO Expiration Date: 11a. Citizenship: US Citizen/Nationalized Lawfully Admitted Alien/Refugee 11b. If not fluent in English, what language do you prefer to use? Cuban Entrant Haitian Entrant Other 12. I hereby apply for the period beginning: _____________________________________________________________________ Employer ID # ___________________________________________ 13. Type Of Industry Employer: 15. Name of Employer at time of Pandemic: 14. Unemployment was a result of COVID-19 because: Employer's Street Address Dates Worked: Occupation: FROM: TO: City County State Zip Mo. Day Year Mo. Day Year Supervisor’s Name: County in which worked: Total Gross Earnings Employer's Telephone Number: Salary Rate: Total Gross Earnings since ( ) — $ Per * Sunday of this week: $ (*Hour, Week, Month, Year) Occupation or Title: DEPARTMENT OF ECONOMIC OPPORTUNITY REEMPLOYMENT ASSISTANCE APPLICATION FOR SERVICES Form ETA-81 (Rev. 03/12) Reason for Separation: Permanent Lay-off Suspension Temporary Lay-off Leave of Absence Tools/Equipment Used: Quit or Voluntary Lay-off Discharged, Job Performance Working Reduced Hours Discharged, Other Are you scheduled to return to work for this employer? Explain Reason for Separation: YES When? NO 16. Are you currently employed, self-employed or have you been self-employed in the past year? YES NO 17. Is there any reason you cannot seek or accept full-time employment? 17A. Have you refused any offer of work since you became unemployed? YES NO YES NO 18. Did you apply for or receive, or would you be eligible to receive if applied for: (Mark "Y" for Yes or "N" for No next to each question) Any amount for loss of wages due to illness or disability? Any amount of retirement pension or annuity income? Any type of private income protection insurance? Worker's compensation for death of head of household? Any amount as supplemental unemployment benefit? ___________________________________________________________ 19. Have you received, or will you receive any of the following payments? Severance Pay YES NO Amount: $ Wages in Lieu of Notice YES NO Vacation Pay YES NO From: To: 20. Do you have specific plans to enroll in or attend school or vocational training within the next 12 months? YES NO If yes, when? (date) 21. Are you receiving, or will you receive a retirement pension? YES NO If yes, date payment began/will begin: Employer's Name: 22. During the past 18 months, have you: a. Been in the Military Service? YES NO b. Held a Federal Civilian Job? YES NO c. Worked in any other state? YES NO 23. Have you applied for Reemployment Assistance benefits in the past 12 months? If yes, against which state? YES NO 24. If you receive, or will receive payments from Worker's Compensation, is it classified as: Temporary Total YES NO Temporary Partial YES NO Impairment Income YES NO Permanent Total YES NO Supplemental Income YES NO 25. Are you a member of a labor union which finds/obtains work for its members? YES NO If yes, provide Union name and number: 26. What type of work are you seeking? 27. Are you a veteran who meets one or more of the following conditions? YES NO a. Served on active duty for a period of more than 180 days and received a discharge other than dishonorable. b. Was a reservist who earned a campaign badge and was released or discharged with a discharge other than dishonorable? c. Was discharged or released from active duty because of a service-connected disability? If you answered yes to Question 27 above, please answer questions 28 – 32 below, otherwise go to question 33. 28. Were you released from military active duty within the last three years (36 months)? YES NO 29. Did you serve on active duty during a war, campaign or expedition for which a campaign badge has been authorized? YES NO 30. Are you a Disabled Veteran? YES NO Definition: You have a service-connected disability which entitles you to compensation or caused you to be discharged or released from active duty. 31. Are you a Special Disabled Veteran? YES NO Definition: You are entitled to compensation for a service-connected disability rated at 30 percent or more or 10 or 20 percent with a determination that you have a serious employment handicap or you were discharged or released from active duty because of service-connected disability. 32. Are you a homeless veteran? YES NO 33. Are you the spouse of any of the following individuals? YES NO (a) a veteran who died of a service connected disability; (b) a veteran who has a total service-connected disability; (c) a member of the Armed Forces serving on active duty who has been listed for a total of more than 90 days in one of the following categories: (I) missing in action; (II) captured in line of duty by a hostile force; or (III) forcibly detained in the line of duty by a foreign government? 34. If you answered ‘Yes’ to Question 27 or 33 above, you qualify for Special Job Service Veteran’s Assistance through the local One Stop Center in your area and, unless told otherwise at the time you complete this application, you should report to that office to register for Veteran’s assistance. DEPARTMENT OF ECONOMIC OPPORTUNITY REEMPLOYMENT ASSISTANCE APPLICATION FOR SERVICES Form ETA-81 (Rev. 03/12) I hereby claim benefits under the Florida Reemployment Assistance Law. I am not seeking benefits under any other state or Federal system. At the discretion of the department, this application for benefits may be accepted as my registration for work and employment services. I understand the Florida Reemployment Assistance Law provides penalties for knowingly making false statements for the purpose of obtaining benefits. I declare that the statements made in connection with this claim are true and correct to the best of my knowledge and belief. I understand the information is subject to verification and agree to provide such documentation as required. Claimant Signature: Date: The Department of Economic Opportunity may e-mail me for additional information needed in determining my claim. My E-Mail Address is:__________________________________________________ I understand the Department of Economic Opportunity will maintain the confidentiality of my e-mail address pursuant to section 443.1715, Florida Statutes. *PRIVACY ACT STATEMENT Information you provide to this department is voluntary and confidential but is required to process your claim. Pursuant to the Internal Revenue Code of 1986, the Social Security Act, 42 U.S.C. 1320b-7(a)1, and s. 443.091(1)(h), F.S., disclosure of your Social Security number is mandatory. Social Security numbers will be used by the department to report the benefits you receive to the Internal Revenue Service as potential taxable income. In accordance with the Federal Deficit Reduction Act, an amendment to the Federal Social Security Act, and 5 U.S.C. 552a(o)(1)(D), information you provide is subject to verification through computer matching programs and information about your wages and claim may be provided to other federal, state and local agencies or their contractors for verification of eligibility under other government programs to ensure benefits have been properly paid and for statistical and research purposes. An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Please mail to the following address: Florida Department of Economic Opportunity P.O. Box 5350 Tallahassee, FL 32314-5350 Form ETA-81 Supplement (Rev. 03/12) REEMPLOYMENT ASSISTANCE APPLICATION SUPPLEMENT 35. *Social Security Number: — — 36. WORK HISTORY: Complete the following in blue or black ink for the last 3 jobs you have held DURING THE PAST 18 MONTHS PRIOR to the employment you listed in item 12 of the UC310 form. Include self-employment, part-time work, military service, and employment with a government agency. Include all employers regardless of location, type of work performed, or length of job. Next Most Recent Employer: Employer ID # (For Office Use Only) Employer’s Street Address: Dates Worked: FROM: TO: City: State: Zip: Total Gross Earnings with this Employer: $ Employer’s Local Mailing Address (if different than above): Total Gross Earnings with this Employer Since Sunday of this Week: $ City: State: Zip: Occupation or Position Title: Employer’s Telephone Number: ( ) — Tools/Equipment used: Reason for Separation: Permanent Lay-off Temporary Lay-off Quit or Voluntary Lay-off Working Reduced Hours Suspension Leave of Absence Discharge, Job Performance Discharged, Other Salary Rate: $ Per: (Hour, Week, Month, Year) Explain Reason for Separation: Next Most Recent Employer: Employer ID # (for Office Use Only) Employer’s Street Address: Dates Worked: FROM: TO: City: State: Zip: Total Gross Earnings with this Employer: $ Employer’s Local Mailing Address (if different than above): Total Gross Earnings with this Employer Since Sunday of this Week: $ City: State: Zip: Occupation or Position Title: Employer’s Telephone Number: ( ) — Tools/Equipment used: Reason for Separation: Permanent Lay-off Temporary Lay-off Quit or Voluntary Lay-off Working Reduced Hours Suspension Leave of Absence Discharge, Job Performance Discharged, Other Salary Rate: $ Per: (Hour, Week, Month, Year) Explain Reason for Separation: Next Most Recent Employer: Employer ID # (For Office Use Only) Employer’s Street Address: Dates Worked: FROM: TO: City: State: Zip: Total Gross Earnings with this Employer: $ Employer’s Local Mailing Address (if different than above): Total Gross Earnings with this Employer Since Sunday of this Week: $ City: State: Zip: Occupation or Position Title: Employer’s Telephone Number: ( ) — Tools/Equipment used: Reason for Separation: Permanent Lay-off Temporary Lay-off Quit or Voluntary Lay-off Working Reduced Hours Suspension Leave of Absence Discharge, Job Performance Discharged, Other Salary Rate: $ Per: (Hour, Week, Month, Year) Explain Reason for Separation: *PRIVACY ACT STATEMENT Information you provide to this department is voluntary and confidential but is required to process your claim. Pursuant to the Internal Revenue Code of 1986, the Social Security Act, 42 U.S.C. 1320b-7(a)1, and s. 443.091(1)(h), F.S., disclosure of your Social Security number is mandatory. Social Security numbers will be used by the department to report the benefits you receive to the Internal Revenue Service as potential taxable income. In accordance with the Federal Deficit Reduction Act, an amendment to the Federal Social Security Act, and 5 U.S.C. 552a(o)(1)(D), information you provide is subject to verification through computer matching programs and information about your wages and claim may be provided to other federal, state and local agencies or their contractors for verification of eligibility under other government programs to ensure benefits have been properly paid and for statistical and research purposes. An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Ron DeSantis Governor Ken Lawson Executive Director REEMPLOYMENT ASSISTANCE PROGRAM PO BOX 5250 TALLAHASSEE, FL 32314-5250 C Florida Reemployment Assistance Way2Go Debit Card Fee Schedule Below are the Debit Card Fee schedules you have reviewed and acknowledged. Depending on the Florida Reemployment Assistance Way2Go Debit Card services you utilize, you may be responsible for these fees. Florida Reemployment Assistance Prepaid Card issued by Comerica You have several options to receive your payments: direct deposit to your bank account; direct deposit to your own prepaid account; or this prepaid card. You do not have to accept this prepaid card. Ask about other ways to receive your funds. Monthly fee $0 Per purchase $0 ATM withdrawal $0 (in-network) $1.90 (out-of-network) Cash reload N/A ATM balance inquiry (in-network or out-of-network) $0 or $0.75 Customer service (automated or live agent) $0.50* Inactivity $0 We charge 2 other types of fees. Here they are. Card replacement (regular or expedited delivery) $4* or $18.50* Over the counter teller cash withdrawal $3.00* * This fee can be lower depending on how and where this card is used. See separate disclosure for ways to access your funds and balance information for no fee. You are allowed one regular card replacement for no fee per benefit period. No overdraft/credit feature Your funds are eligible for FDIC insurance. For general information about prepaid accounts, visit cfpb.gov/prepaid. Find details and conditions for all fees and services in the cardholder agreement. I have reviewed the Florida Reemployment Assistance Way2Go Debit Card Fee Schedule and understand that if I choose Florida Reemployment Assistance Way2Go Debit Card as my payment method and use the above services that I will be responsible for any fees charged for those services. All Fees Amount Details Get Started Card purchase $0 There is no fee to obtain a Card account. Spend money Point-of-sale (POS) $0.00 There is no fee for POS purchase transactions conducted in the U.S. using your signature or PIN number. Get Cash ATM Withdrawal (in-network) $0 There is no fee for in-network ATM withdrawals conducted at Comerica and MoneyPass ATM locations. In-network refers to Comerica and MoneyPass ATM locations. In-network locations can be found at https://locations.comerica.com/ and moneypass.com/atm-locator.html. When using your card at an ATM, the maximum amount that can be withdrawn from your Card account per calendar day is $500.00. ATM Withdrawal (out-of-network) $1.90 This is our fee. “Out-of-network” refers to all ATMs outside of the MoneyPass or Comerica Bank ATM Network. You will be assessed a fee for each ATM withdrawal conducted at an out-of-network ATM. You may also be charged a fee by the ATM operator, even if you do not complete a transaction. When using your card at an ATM, the maximum amount that can be withdrawn from your Card account per calendar day is $500.00. Teller-assisted cash withdrawals (OTC)* $3.00 This is our fee. You are allowed one (1) withdrawal per deposit for no fee at Mastercard Member Bank or Credit Union teller windows. Each additional withdrawal will be assessed the fee. Information Customer service (automated or live agent)* $0.50* You are allowed five (5) calls to Customer Service Interactive Voice Response (IVR) or live agent for no fee each month to check your balance or hear your transaction history. Each additional call will be assessed the fee. ATM balance inquiry (in-network) $0 There is no fee for ATM balance inquires conducted at MoneyPass and Comerica Bank ATM networks. ATM balance inquiry (out-of-network) $0.75 This is our fee. Each ATM balance inquiry conducted at an out-of-network ATM will be assessed a fee. Using your card outside the U.S. International transaction fee 3% Conversion rate is a Mastercard fee for each transaction amount conducted outside of the U.S. Other Card replacement $4 You are allowed one (1) card replacement for no fee per benefit period. Each additional card replacement request will be assessed a fee. Cards are sent via regular mail. Standard delivery is 7 to 10 calendar days. Expedited card delivery $14.50 If you request your replacement card to be expedited rather than receiving it by regular mail, you will be assessed the expedited card delivery fee, in addition to any applicable card replacement fee. Expedited card delivery can be expected within 3 to 5 calendar days. Funds transfer via Interactive Voice Response (IVR-phone) or web portal $0.00 There is no fee for you to transfer funds from your card account to a U.S. bank account owned by you. * ”No Fee” transactions expire at the end of each calendar month if not used. Your funds are eligible for FDIC insurance and will be held at or transferred to Comerica Bank, an FDIC-insured institution. Once there, your funds are insured up to $250,000 by the FDIC in the event Comerica Bank fails, if specific deposit insurance requirements are met. See fdic.gov/deposit/deposits/prepaid.html for details. No overdraft/credit feature. Contact Go Program Customer Service by calling 1-833-888-2780, by mail at P.O. Box 245997, San Antonio, TX 78224-5997 or visit www.GoProgram.com. For general information about prepaid accounts, visit cfpb.gov/prepaid. If you have a complaint about a prepaid account, call the Consumer Financial Protection Bureau at 1-855-411-2372 or visit cfpb.gov/complaint. List of all fees for Florida Reemployment Assistance Way2Go Card Prepaid Card
