WARNING: Committing an act of unemployment fraud may result in loss of current and future benefits,
penalties, fines and imprisonment.
EMPLOYEE NAME_________________________________________________(print)
EMPLOYEE SOCIAL SECURITY NUMBER_____________________________________
I authorize my employer, _________________________________________________________, to file weekly claims for benefits
(Partials) for me in the event that the business is closed temporarily. By authorizing my employer to file these claims, I allow
him/her to report the following information on my behalf:
Citizenship status - for employees who are not citizens, the employer will provide a copy of your employment
authorization card to the Payment Processing Unit. Fax number (334)956-7483.
Federal Tax Withholding preference - you may choose to have Federal Tax withheld (at the rate of 10%) from your
Unemployment Compensation benefits. This form allows you to authorize the employer to report your choice:
_______Yes _______ No.
Statistical information - race, sex, disability status, highest grade completed.
Amount of pay received from the employer - the employer will report any pay you are owed for the week being
Amount of pay received from outside sources (the employer will report any pay you received from other employment
or other sources.) You must let the employer know if you have pay from an outside source for the week being
claimed. If the pay is not reported by the employer, notify
the Payment Processing Unit at (334)956-7481.
I understand that I must provide my employer with my current mailing address. If my address changes, it is my responsibility to
notify my employer immediately. I understand that, if I provide an incorrect address, the Postal Service will not forward my AL
Vantage Debit Card. I understand that if I feel an error has been made in the information provided, I should notify the Payment
Processing Unit immediately.
I understand that I must make a payment selection method by calling the automated system at 800-499-2035. I understand I can
use this system to enter my direct deposit information or to select the AL Vantage Prepaid Benefits Card. I further understand
my employer-filed claim will not be complete, and will not be processed, until I have used this automated system to select my
payment method.
I also understand that I will receive a Monetary Determination in the mail when I file a new claim that shows my base period
wages. If wages are missing from this report, I must notify the Payment Processing Unit immediately. (Wages with the Federal
Government, Military or employers outside of Alabama will not be included on the report.
Please notify the Payment Processing Unit if you have any of these types of wages.)
EXCLUSIONS: Employees who receive a pension, worker’s compensation payments, or are in school are required to inform the
employer that a partial claim should not be filed for them. The employer should request and file paper Ben-3 forms which will be
required to be submitted to the Payment Processing Unit.
I understand all of the information above and agree to the terms. I understand that this form must be completed and returned to
the Payment Processing Unit prior to a Partial claim being filed.
SIGNATURE _______________________________________________________
DATE OF CONSENT _________________________________________________
334 956-7481
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