Name: ______________________________________________
Week Beginning (Sunday - mm/dd/yy):_______________
Claimant ID or SSN: _______________________________
Week Ending (Saturday - mm/dd/yy):
_________________
Wages/Earnings Sun Mon Tue Wed Thu Fri Sat
Total
Hours
Pay
Rate
Gross
Pay
Regular Hours
Overtime Hours
Orientation/Training
Other Hourly Income
Tips
Commission
*
Other Income/Cash
*
Other Income/Cash (Reportable Income)
This form is for use as an earnings log for work performed during a continued claim week. Earnings are required to be reported during the
week in which they were earned. Record your hours worked and enter the rate of pay. Gross wages are calculated by multiplying the total
hours worked by the rate of pay. Enter any tips, commissions, or other type of pay for the day in which it was earned. You may copy this form
for your records and additional copies can be found at UI.NV.GOV on the For UI Claimants tab in the I Want To section.
Weekly Total (total of all gross pay types)
Hours x Rate = Gross Pay
If you answer YES to the question "Even though you may not have been paid your wages, Did you work during the week...?",
your wages must be reported in the week in which you actually worked, not when paid.
Fees
Stand By Time
Independent Contractor
Casual Labor
Comp Time
Picket Pay
Self-Employment
Room and Board
Rent and Utilities
AARP/Title V SCSEP Grant worker
National Guard/Military Reserve two-week training
All periods of Active Military Duty
Report suspected UI Fraud onlineat https://uifraud.nvdetr.org
Date
Rev (Dec 2017)
