DEPARTMENT OF LABOR & INDUSTRY
OFFICE OF UNEMPLOYMENT COMPENSATION BENEFITS POLICY
EMPLOYER INFORMATION
THIS FORM PROVIDES THE EMPLOYEE WITH THE EMPLOYER’S
INFORMATION TO BE USED IF HE/SHE WISHES TO APPLY FOR
UNEMPLOYMENT COMPENSATION BENEFITS.
Employer: You must provide this completed form to separating employees and/or employees working reduced hours. It is
important for the claimant to use accurate information and include the PA Unemployment Compensation (UC) account number
when ling for UC benets. By doing so, the department can ensure that employers receive requests for separation information
timely. Providing this form to employees can help reduce inaccurate UC benet charges to your account that may increase your
UC tax rate.
Employee: Unemployment Compensation (UC) benets are available to workers who are unemployed and who meet the
requirements of state UC eligibility laws. You may file a UC claim in the first week that employment stops or work hours are
reduced. For more information about how to file and what you need when you contact us, see page 2 of this form.
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Employer PA UC Acct. No.:
(seven-digit number followed by R or M, or enter zero)
Employer Legal Name:
(as it appears on the PA Enterprise Registration Form PA-100)
Employer Address (or TPA address):
City: State: Zip:
Contact Person: Title:
Phone: Fax: Email:
Complete the section below only if the employee is expected to return to work at your company.
Employee Name: Last 4 digits of Social Security no.:
Expected Date of Recall (MM/DD/YY)
Employer Representative Signature Date
INSTRUCTIONS FOR EMPLOYERS WHEN COMPLETING THIS FORM
PA Employer UC Account Number This seven-digit number is shown on the New Employer Conrmation Letter (Form
UC-1408), Notice of Pennsylvania Unemployment Compensation Responsibilities (Form UC-851), and the Contribution Rate
Notice (Form UC-657). If an account number has not been assigned, please register with the department by submitting
the Pennsylvania Enterprise Registration Form (PA-100) at www.pa100.state.pa.us. The UC number is also on the
UC-44FR (Request for Relief from Charges), UC-44F(3) (Notice of Financial Determination), and the UC-640 (Monthly Notice
of Compensation Charged).
Employer Address - Enter your mailing address or the address where you want the Employer’s Notice of Application
(UC-45), unemployment fact-nding forms, and determinations to be mailed. If your company uses a Third-Party Administrator
(TPA) to handle your unemployment claims, please enter the address for the TPA. If your address changes, please complete
the UC-1212 online at www.uc.pa.gov.
Contact Person, Email Address - Provide the name, title, telephone number, fax number and email address of the human
resource representative in your company that the department can contact if additional separation information is needed.
SIDES: STATE INFORMATION DATA EXCHANGE SYSTEM
SIDES E-Response enables employers to receive and respond securely to Pennsylvania’s Employers’ Notice
of Application (UC-45) ELECTRONICALLY, rather than by mail. For the form to enroll (UC-504) to this free-of-charge
program or for more information on SIDES, please go to the Employers’ section of our website: www.uc.pa.gov.
UC-1609 REV 04-20 (Page 1)
