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 benets. 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 benet charges to your account that may increase your
UC tax rate.
Employee: Unemployment Compensation (UC) benets 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 Conrmation 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)
INSTRUCTIONS FOR EMPLOYEES WHEN
FILING AN APPLICATION FOR UNEMPLOYMENT COMPENSATION BENEFITS
When to le: If you have worked your full, regular hours for this work week, then le on Sunday following
your last day of work. If your separation from your employer caused a change to your normal working hours
for the week, then le right away.
What you need to provide in order for the department to process your application:
Full legal name
Social Security Number
Your authorization to work (if you are not a US Citizen or resident)
Home address and mailing address (if dierent)
Telephone number
Valid email address
PIN -Personal Identication Number (optional) - if you have previously led a UC claim using your
previous PIN can prevent you from having to re-enter information.
Direct Deposit bank information (optional) - bank name, address, account and routing number
Employer information: Use the information on the front of this form to enter the employer address
and account number
First and last day worked with employer
Reason for leaving
Pension or severance package information (if applicable)
Dierent Ways to File:
Online: Complete an online application using our secure website 7 days a week,
24 hours a day at www.uc.pa.gov or by scanning the QR code on this form.
Phone: Call the statewide toll-free number 888-313-7284.
TTY: Services for the Deaf and Hard of Hearing is available at 888-334-4046.
Paper Form: A paper application can be downloaded from the website www.uc.pa.gov
and mailed to the address indicated on the instructions. This method of ling can take
longer to process.
Videophone Services: Individuals who use American Sign Language (ASL) can call
717-704-8474 every Wednesday from noon to 4 p.m.
If you have questions about the status of your UC claim, you can call 1-888-313-7284 or e-mail
uchelp@pa.gov.
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
UC-1609 REV 04-20 (Page 2)