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UIA 1260 Authorized by
(Rev. 5-15) MCL 421.1, et seq.
State of Michigan
Talent Investment Agency
UNEMPLOYMENT INSURANCE AGENCY
www.michigan.gov/uia
Employer Remuneration Questionnaire
Mail Date:
Claimant’s Name:Employer Name:
Employer Address: Michigan Identity Number:
Employer Account Number:
To whom it may concern,
As an authorized representative of the Unemployment Insurance Agency, the Multi Claimant Unit determines
eligibility for unemployment benets when one or more individuals of the same employing unit are separated
under similar or related circumstances.
Please supply information for the above-named unemployed worker and any others involved using the table
provided. In order to properly process these claims, it is essential that you complete this form in its entirety.
______ On a separate sheet of paper, please provide the 1. How many individuals are involved?
name(s), Social Security number(s), the type and amount of payment for all involved.
2. What type(s) of payment was/were issued on or after the individual’s last day of work?
How were the payment(s) made? (e.g. weekly, bi-weekly, semi-monthly, monthly, lump sum, or other.)3.
Is the payment allocated (will the payment cover a specic time period other than the week in which it is
paid)? Please provide the amount and the dates for each period covered. (Please see reverse side.) If
the individuals received holiday pay or vacation pay, please provide the amount for each type of
4.
payment separately.
5. If the payment was not to cover a specic period, provide the date issued and the amount of the
payment.
6. Was the payment issued based on a union contract or other agreement? If so, please provide a copy.
Were the individuals informed in advance of this payment and that it would be covering a specic
period? If notice was in writing, please provide a copy of the notice. (Only required for vacation pay.)
7.
If the unemployed worker is receiving vacation pay, did he/she request the vacation pay in lieu of time
off?
8.
If you have any questions, please contact the Multi Claimant Unit at 313-456-2750.
TIAis an equal opportunity Employer/Program.
Reset Form
UIA 1260
(Rev. 05-15
Page 2
From Through
Bonus
Severance
Holiday
Separation/Termination
Salary/Wage Continuation
Payment in Lieu of Notice
Sick
Vacation
Transition
Other
PAYMENT TYPE Payment Allocation Period
PAYMENT
METHOD
Weekly Bi-Weekly Monthly
Semi-
Monthly
Lump
Sum
Date Issued Amount
Yes No Yes No Yes No Yes No Ye s No
Bonus
Severance
Holiday
Separation
Salary/Wage
Continuation
Payment in Lieu of
Notice
Sick
Vacation
Transition
Other
Please mail or fax this form to the address or fax number provided below. Section 32(b)(3) of the MES
Act requires that you respond to this request within ten days from the date of mailing.
Name:
______________________________
Please Print
Signature: _________________________________ Title: _____________________________________
Telephone Number: __________________________ Date:_________________
Mail to: Cadillac Place
Multi Claimant Unit
3024 W. Grand Blvd., Ste. 12-450
Detroit, Michigan 48202
Or fax to: 313-456-2755
Claimant Name:
MIN:
Employer Name:
Account Number:
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Completed 13 July 2021

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