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Benefit Forms
What If I Was Instructed to Complete a Form?
The following forms may be used if you have been notified by a department representative that you must provide additional information for the department to make a decision regarding your eligibility.
Simply click on the appropriate form number below, print the form, complete all of the required information and mail or fax it according to the instructions that were given to you by the department.
| Unemployment Insurance PO Box 45266 Salt Lake City, Utah 84145-0266 |
Fax: (801) 526-4402 |
These links are to Adobe Acrobat PDF files. You will need the Acrobat Reader to view and print these files. If you do not have the Reader, click on the icon below to download it for free.
Utah Unemployment Insurance Forms
|
Form Number |
Form Title |
| 602T | Responsibilities While Waived from Training |
| 615CV | Statement Regarding Claim for Benefits - Vacation/Severance Pay |
| 615CW | Statement Regarding Claim for Benefits - Workers Compensation |
| 615W | Trade Adjustment Assistance Training Waiver Decision |
| 615-T | Trade Adjustment Assistance Reform Act of 2002 Training Waiver Decision |
| 617 | Appeal From Decision Of Representative |
| 653D | Deferral Verification Report |
| 661 | Medical Report |
| 669 | Notice to Employer of Wage Assignment Due to Grievance |
| 680Q | Claimant Statement of Voluntary Quit |
| 680-T1/T2 | Claimant Statement of Job Discharge (pages 1 & 2) |
| 681A | Verification of Training and Funding for Department Approval |
| 681R | Request for Extension of Department Approved Training |
| 682 | Electronic Payment Authorization Form for Payment of UI Benefits |
| CWSC | Claimant Work Search Contacts |