Fillable INITIAL CLAIM FORM Ethnicity: (Select all that apply) (Oregon)

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INITIAL CLAIM FORM Ethnicity: (Select all that apply) (Oregon)

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  • 9 check-boxes
  • 8 other fields

Country of origin: US
File type: PDF

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INITIAL CLAIM FORM
• When a date is required, please provide the month, day and year in the following format: 01/01/2001
• To complete your initial claim, you must add your signature and the date of signing. Once complete, return this form to
your employer as soon as possible.
Social Security Number: Name: (Last, First, MI) Phone:
Applicant’s Mailing Address: (Street or P.O.) City: State: Zip Code:
Ethnicity: (Select all that apply)
American Indian or Alaska Native
Asian
Hispanic
Hawaiian Native or Other Pacific Islander
Asian & Pacific Islander
Other
Date of Birth:
Male
Female
Work Share Employer: Phone:
Work Address: (Street or P.O.)
Employment Start Date:
City: State: Zip Code: Job Title:
Yes No
In the last 18 months:
A.
Did you work for an agency of the Federal Government?
B.
Have you served in the Armed Forces?
Yes No
If
yes, dates of service: to
C.
Did you work for an employer in another state? Yes No
If
yes, please list the employer on the next page
D.
Did you file a claim for benefits against any other state? Yes No
If
yes, which state:
E.
Did you work as a professional athlete? Yes No
G. Are you receiving or will
you
r
ec
eive retirement pay (other than
Social Security) within the next 12
Months?
Yes No
If yes, who is your retirement
with:
Amount per month:
$
When did you last work with this
employer:
Yes No
F. Are you a U.S. citizen?
If no, can you legally work in this country?
If yes, please provide your work authorization number:
Yes No
H. Do you require information in a language other than English?
If yes, what is your primary language:
Oregon Employment Department | www.Employment.Oregon.gov (Form 1697 Revised 0117)
Page 1 of 2
Yes No
If
yes, dates employed: to
IMPORTANT: Please answer ALL questions completely. Failure to do so may result in denial of benefits.
For Office Use Only
Yes
No
Approved
Denied
If denied, reason for denial:
Date Received:
Application:
Examiner:
Date of Review:
Plan #:
Current Employer?
Please list all of your Employers for the past two (2) years. Include temporary or employee leasing agencies,
employers in and outside the USA, the federal government and the military. To list more employers, use a
separate piece of paper and attach it to this form. This information will be verified with your employer(s).
First Most Recent Employer: Phone:
I worked for this employer from:
to:
Check One:
Still Working Leave of Absence
Lack of Work
Quit
Strike/Lockout
Fired/Suspended
Total (gross) earnings in above period
of work:
$
Rate of pay: $
HR Day WK MO YR
Address: (Street or P.O.)
City:
Job Title:
Second Most Recent Employer: Phone:
I worked for this employer from:
to:
Check One:
Still Working Leave of Absence
Lack of Work
Quit
Strike/Lockout
Fired/Suspended
Address: (Street or P.O.)
City:
Job Title:
Third Most Recent Employer: Phone:
I worked for this employer from:
to:
Check One:
Still Working Leave of Absence
Lack of Work Quit
Strike/Lockout
Fired/Suspended
Total gross earnings in above period
of work:
$
Address: (Street or P.O.):
City:
Job Title:
Oregon Employment Department | www.Employment.Oregon.gov (Form 1697 Revised 0117)
Total (gross) earnings in above period
of work:
$
Rate of pay: $:
HR Day WK MO YR
Rate of pay: $
HR Day WK MO YR
State
ZIP
ZIP
ZIP
State
State
Signature:
Date:
Oregon Employment Department • Attn: UI Special Programs Center• PO Box 14518 • Salem, Oregon • 97309
Phone: (503) 947-1800 • Fax: (503) 947-1833 • OED_workshare@oregon.gov
Disclaimer: If you send this form via email, it may not be secure. If you do not utilize email encryption software we advise you contact the UI Special Program Center at
(503) 947-1800 or (800) 436-6191 to sign up with our secure email server. By clicking the submit button you acknowledge that you are responsible for ensuring the protection of the
personally identifiable information included in this email.
I certify under penalty of perjury that I am a citizen of the United States or legally authorized to work in the United States. I understand the questions I have been asked and my answers are true
to the best of my knowledge. I understand the law provides penalties for making false statements in order to obtain unemployment insurance benefits. By submitting this application, I hereby
request an initial determination of benefits potentially payable to me. I authorize the Employment Department to obtain and use information from any source I provide for administering
unemployment insurance. Following this signed Initial Claim form, I understand and authorize my employer to submit Weekly Claim Certification forms on my behalf. I understand I
am also responsible for communicating with my employer and the Oregon Employment Department of any changes to my status. I understand that failure to communicate status
changes can result in a delay or denial of benefits. I further understand that any overpayment or misinformation is my responsibility. I understand that I can check the status of my
claim by calling the Unemployment Insurance (UI) Special Programs Center at the number listed below.
By checking this box, I certify that I understand that it is my responsibility to know the information in both the Claimant and Work Share Handbooks.
**By signing this form electronically, I understand that this electronic signature has the same meaning and validity as my handwritten signature.
These handbooks can be found at www.OregonWorkShare.org
The Oregon Employment Department is an equal opportunity employer/program. Auxiliary aids and
services, and alternate formats are available to individua
ls with disabilities and language services to
individuals with limited English proficiency free of cost upon request. TTY/TDD-dial 7-1-1 toll free relay
service. Access free online relay service at: www.sprintrelayonline.com.
El Departmento de Empleo de Oregon es un programa que respeta la igualdad de opportunidades.
Disponemos de servicios o ayudasauxiliares, formatos alternos para personas con conocimiento
limitadodel ingles, a pedido y sin costo.Llame al 7-1-1 para asistencia gratuita TTY/TDD para personas
con dificultades auditivas. Obtenga acceso gratis en internetpor medio del siguiente sitio:
www.sprintrelayonline.com.
Page 2 of 2
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INITIAL CLAIM FORM Ethnicity: (Select all that apply) (Oregon)

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Completed 16 March 2021

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