If you have applied for or have been receiving unemployment insurance benefits payments, it is
your responsibility (under penalty of law) to notify the appropriate local office in writing to
discontinue the issuance of unemployment insurance checks once you are employed. Failure to
notify the state agency can result in a penalty, such as a fine, imprisonment, or both.
U.S. Department of State
UNEMPLOYMENT INSURANCE BENEFITS
DS-7665
05-2015
Employee's Signature Date (mm-dd-yyyy)
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signature
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