Fillable Claimants Statement of Wages (Michigan)

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Claimants Statement of Wages (Michigan)

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STATE OF MICHIGAN
GRETCHEN WHITMER DEPARTMENT OF LABOR AND ECONOMIC OPPORTUNITY JEFF DONOFRIO
GOVERNOR UNEMPLOYMENT INSURANCE AGENCY DIRECTOR
Authorized by
MCL 421.1 et seq.
UIA 1718
(Rev. 06-19)
UIA is an equal opportunity employer/program.
•
*017181906*
•
Mail Date:
Claimant’s Statement of Wages
Employers are required to report quarterly wages for each employee to the Unemployment Insurance Agency (UIA).
A claim for unemployment benets is based on these reported wages. You were sent a Monetary Determination that
provided information regarding your claim for unemployment benets. This monetary determination showed you the
wages reported by your employers and/or informed you that an employer(s) did not report wages for you.
This Form UIA 1718, Claimant’s Statement of Wages, must be completed by you if either you disagree with the
wages reported by an employer or an employer did not report wages for you at all. Carefully read and follow the
directions to complete this form. Mail to the Unemployment Insurance Agency, P.O. Box 169, Grand Rapids, MI
49501-0169 or Fax at 1-517-636-0427.
Check the reason you are completing this form:
Wages earned with _________________________________that I included on my claim for unemployment
Name of Employer
benets were not included in the calculation of my Monetary Determination.
I disagree with the wages reported by ______________________________ as shown on my Monetary
Name of Employer
Determination.
I never worked for or was not paid by _______________________________ as shown on my Monetary
Name of Employer
Determination and to request the reported wages not be used. Complete Section E only.
Section A - Claimant Information
____________________________________________ _________________________________
First and Last name Social Security Number
Section B - Employer Information
____________________________________________ _________________________________
Name of Company or Business Owner/Employer Name
____________________________ _________________________ ___________________________
Telephone Number UIA Employer Account Number Federal Employer Identication Number (FEIN)
____________________________________________________________________________________________
Address City State Zip Code
Section C - Employment Information
Physical location of your employment: _____________________________________________________________
Type of work you performed or your job title: ________________________________________________________
Reset Form
UIA 1718
(Rev. 06-19)
Letter ID:
How were you paid?
Cash Check
Direct deposit
Other - explain: ____________________
Was there other remuneration (e.g. bonuses, commissions, 401K, room and board, etc.) in your wages?
No
Yes - explain:
Were deductions made from your pay (e.g. FICA, income taxes, etc.) in your wages?
No
Yes
Total gross wages during current calendar year: $____________________
actual
estimated
Total gross wages during preceding calendar year: $__________________
actual
estimated
Were there other employees?
No
Yes - how many? ______________
Is the employer still operating?
No
Yes
Additional comments:
Section D - Quarterly Wage Information
You must report the quarterly gross wages (before taxes) on the chart on the next page. There are four calendar
quarters per year. The quarters are numbered and are the same from year to year. Each quarter contains three
calendar months as follows:
1st Quarter January 1 through March 31
2nd Quarter April 1 through June 30
3rd Quarter July 1 through September 30
4th Quarter October 1 through December 31
The involved quarters are the same quarters that are shown on your Monetary Determination under the heading
“Monetary Determination Calculations”. Label the chart on the next page with the same quarter dates.
• If you are completing this form because wages earned with an employer that you included on your
claim were not used in the calculation of your Monetary Determination, complete all quarters that
contained wages from that employer.
• If you are completing this form because you disagree with the wages reported by your employer,
complete only the quarters that you disagree with.
If your address changes, it is important to update it with the Unemployment Insurance Agency.
If you have questions, you may contact us through your MiWAM account or by calling 1-866-500-0017. For
telephone or Local Oce hours of operation, visit www.michigan.gov/uia. TTY service is available at
1-866-366-0004.
These quarterly charts allow you to enter wage information per week to help you determine your quarterly total wages. If you know your gross wages for
each quarter, complete only the Total Quarterly Wage box for each involved quarter. Wages are reported in the quarter they are paid to you.
Example: You may have worked during the last week of March (1st quarter), but you were not paid until April (2nd quarter). These wages must be reported in
the 2nd quarter (the quarter containing the date you were PAID).
You are required to send in clear, legible proof of wages to support the information you provide on this form. This can include check stubs,
W-2s, payroll records, or a letter from the employer with payroll information. Proof of wages must be included in the order for the Unemployment
Insurance Agency to use the information you are providing.
Quarter ___ Year ______
WEEK PAID
GROSS WAGES
PAID
TOTAL
Quarterly
Wages
Quarter ___ Year ______
WEEK PAID
GROSS WAGES
PAID
TOTAL
Quarterly
Wages
Quarter ___ Year ______
WEEK PAID
GROSS WAGES
PAID
TOTAL
Quarterly
Wages
Quarter ___ Year ______
WEEK PAID
GROSS WAGES
PAID
TOTAL
Quarterly
Wages
Quarter ___ Year ______
WEEK PAID
GROSS WAGES
PAID
TOTAL
Quarterly
Wages
Section E - Certication Statement
Certication: I certify that the information I have reported is true and correct. I understand that if I intentionally make a false statement, misrepresent facts or
conceal material information, I may be required to pay damages and could be subject to criminal prosecution.
_____________________________________________________ _______________________
Signature Date
UIA is an equal opportunity employer/program.
•
*017181906*
UIA 1718
(Rev. 06-19)
Letter ID:
•
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Claimants Statement of Wages (Michigan)

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Completed 4 June 2021

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