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UI-501 UNEMPLOYMENT APPLICATION PAGE 1 OF 26 MDES: REV-05062020
INITIATE CLAIM APPLICATION
*REQUIRED INFORMATION
1. *Are you unemployed as a result of a major disaster which occurred in Mississippi and was
declared by the President? COVID-19:
YES NO
2. If disaster is MS COVID-19: effective beginning January 27, 2020 check all that apply:
I have been diagnosed with COVID-19 or am experiencing symptoms of COVI0-19 and am
seeking a medical diagnosis;
A member of my household has been diagnosed with COVID-19;
I am providing care for a family member or a member of my household who has been
diagnosed with COVID-19;
A child or other person in my household for which I have primary caregiving responsibility is
unable to attend school or another facility that is closed as a direct result of the COVID-19
public health emergency and such school or facility care is required for me to work;
I am unable to reach the place of my employment because of a quarantine imposed as a
direct result of the COVID-19 public health emergency;
I am unable to reach the place of my employment because I have been advised by a health
care provider to self-quarantine due to concerns related to COVID-19;
I was scheduled to commence employment and do not have a job or am unable to reach the
job as a direct result of the COVID-19 public health emergency;
I have become the breadwinner or major support for a household because the head of the
household has died as a direct result of COVID-19;
I had to quit my job as a direct result of COVID-19; or
My place of employment is dosed as a direct result of the COVID-19 public health emergency.
I am self-employed and unable to work due to COVID-19.
3. *Date you became unemployed as a direct result of the disaster:
_________ - __________ - _____________________
UI-501 UNEMPLOYMENT APPLICATION PAGE 2 OF 26 MDES: REV-05062020
FILE DISASTER CLAIM
*REQUIRED INFORMATION
1. *County where you were employed before the disaster:
_______________________________________________________
2. *County where you lived at the time or disaster
_______________________________________________________
UI-501 UNEMPLOYMENT APPLICATION PAGE 3 OF 26 MDES: REV-05062020
UI-501 Unemployment Application
Date: __________ - __________ - ______________________
NOTE: PLEASE SHOW ALL DATES AS MM-DD-YYYY (MONTH, DAY, YEAR)
PERSONAL INFORMATION
1. SSN : __________ - ______ - _____________ 2. First Name: _________________________________
3. Middle Initial: _______ 4. Last Name: _________________________________________
5. Other last name worked under during the last 18 months: ___________________________________
6. Date of Birth: __________ - __________ - ______________________
7. Gender:
MALE FEMALE
8. Race: ASIAN AFRICAN AMERICAN CAUCASIAN AMERICAN INDIAN PACIFIC ISLANDER
9. Ethnicity: NOT HISPANIC/LATINO HISPANIC/LATINO
10. Are you a US Citizen? YES NO If No, provide the following
a. Alien Document Type:
VISA PERMANENT RESIDENT 1-55
b. Document #: _________________
c. Exp. Date: __________ - __________ - ______________________
11. Do you have a disability?
YES NO
12. Are you a military veteran, transitional veteran or a spouse of a veteran? YES NO
13. What is the highest grade completed in school? _________________
14. Do you have a state issued driver’s license or identification card?
YES NO
a. If yes, indicate the issuing state ______________________________
UI-501 UNEMPLOYMENT APPLICATION PAGE 4 OF 26 MDES: REV-05062020
IDENTIFICATION VERIFICATION
1. First name (on ID or DL) : _______________________________________
2. Last name (on ID or DL): _______________________________________
3. Date of Birth (on ID or DL): __________ - __________ - ______________________
4. Driver’s License/ID Number: _______________________________________
5. License Class: _______________________________________
6. Issue Date:__________ - __________ - ______________________
7. Expiration Date:__________ - __________ - ______________________
8. Height: _______Feet _______Inches
If the details entered cannot be validated, your claim will be subject to further identification
verification.
CONTACT DETAILS
1. Mailing address: Street: _______________________________________________________
City: ____________________________ State: _____________________________________
Zip Code: ____________________ Country: _______________________________________
Residential address:
Same as mailing address Different
2. Residential address:
Same Different
3. If different, provide details: Street: _______________________________________________________
City: ____________________________ State: _____________________________________
Zip Code: ____________________ Country: _______________________________________
4. If Mississippi resident, County: _______________________________
5. Telephone Number(s)
Primary Number:____________________ 5. Cell Number:____________________
6. Would you like to sign-up to receive notification via text message regarding your reemployment
assistance? Message and data rates may apply.
Yes No
7. How may we contact you?
USPS Mail Email
UI-501 UNEMPLOYMENT APPLICATION PAGE 5 OF 26 MDES: REV-05062020
EMAIL ACKNOWLEDGEMENT
BY CHECKING “I AGREE”, YOU AGREE AND CONSENT TO RECEIVE NOTIFICATION OF UNEMPLOYMENT
INSURANCE CORRESPONDENCE BY EMAIL. YOU WILL RECEIVE AN EMAIL STATING “I AGREE TO THE TERMS
AND CONDITIONS OF MDES REGARDING ELECTRONIC NOTIFICATIONS.” BY PROVIDING YOUR EMAIL ADDRESS,
YOU CAN RECEIVE IMPORTANT INFORMATION FASTER AND MORE EFFICIENTLY. YOU CAN ALSO RESET YOUR
PASSWORD USING OUR CONVENIENT AUTOMATED SYSTEM.
I agree
8. Email Address: _______________________________________
9. Confirm Email Address: _______________________________________
10. Select your correspondence language preference:
ENGLISH SPANISH
SECURITY CONFIRMATION
MDES WILL VALIDATE THE IDENTITY INFORMATION YOU PROVIDED WITH OTHER STATE AND FEDERAL AGENCIES.
REVIEW THE INFORMATION AND MAKE ANY NECESSARY CHANGES.
1. Social Security Number: __________ - ______ - _____________
2. First Name on SS card: _______________________________________
3. Last Name on SS card: _______________________________________
4. Date of Birth: __________ - __________ - ______________________
UI-501 UNEMPLOYMENT APPLICATION PAGE 6 OF 26 MDES: REV-05062020
FILE CLAIM
1. Mark the location where you are filing the claim.
CALL CENTER WIN JOB CENTER OTHER
2. Were you employed with the federal government performing federal civilian service
within the last 18 months?
YES NO
If yes, where did you work? IN USA OUTSIDE USA IN MISSISSIPPI
3. Were you discharged from the US Military within the last 18 months? YES NO
4. Have you worked for any employer within the last 18 months? YES NO
5. List all the states where you worked within the last 18 months,
excluding Federal (Outside of USA) or Military employment.
MISSISSIPPI
STATE #1: _______________________________________ STATE #2: _______________________________________
6. Do you have a definite date to return to full time work? YES NO
a. If yes, indicate the date you expect to return to work below:
__________ - __________ - ______________________
7. Have you applied for Unemployment Insurance Benefits in any state
other than Mississippi in the last 12 months?
YES NO
8. Was your last employer a Headstart employer? YES NO
9. Are you currently unemployed due to the novel coronavirus outbreak (also known as COVID-19)?
YES NO
UI-501 UNEMPLOYMENT APPLICATION PAGE 7 OF 26 MDES: REV-05062020
EMPLOYMENT DETAILS (EMPLOYER #1)
Employer Name: ________________________________________________
Street: _______________________________________________________
City: ____________________________ State: ____________________________
Zip Code: ____________________ Country: ____________________________
1. Did you work for this employer?
YES NO
a. Start Date: _____ - _____ - _____________ b. End Date: _____ - _____ - _____________
c. Job Title/Description: ______________________________________
d. What was your rate of pay? Amount: _____________________
RATE OF PAY: HOURLY DAILY WEEKLY BI MONTHLY MONTHLY YEARLY
e. Reason why you are no longer working with this employer:
LACK OF WORK/LAID OFF DISCHARGE VOLUNTARY QUIT CORONA VIRUS (COVID-19)
LEAVE OF ABSENCE DESIGNATED VACATION STRIKE/LOCKOUT SUSPENSION
i. If Voluntary Quit, select reason:
ATTEND SCHOOL/TRAINING CHILD CARE DISTANCE TO WORK
FAMILY RESPONSIBILITIES HEALTH REASONS MOVE WITH SPOUSE
MOVE WITH SPOUSE-MILITARY NOT PAID CORRECT AMOUNT REDUCED WORK HOURS
RELOCATE START A NEW JOB TO GET MARRIED TRANSPORTATION OTHER
ii. If Discharged/Fired, select reason:
ABSENTEEISM/TARDINESS AWAY FROM WORK STATION DAMAGING COMPANY PROPERTY
FAILED DRUG TEST FALSIFIED DOCUMENTS POOR JOB PERFORMANCE
PHYSICAL ALTERCATION REFUSING TO PERFORM ASSIGNED DUTIES
REFUSING TO WORK OVERTIME SLEEPING ON THE JOB STEALING
SUSPENDED DRIVER’S LICENSE UNAUTHORIZED USE OF COMPANY PROPERTY
UNDER THE INFLUENCE OF ALCOHOL VERBAL ALTERCATION OTHER
f. Are you receiving or are you going to apply for a pension from this employer? YES NO
I. IF YES, PROVIDE THE DATE YOU RECEIVED OR WILL RECEIVE THE PENSION BELOW:
__________ - __________ - ______________________
g. Employer Telephone #: ___________________________________________
h. Are you being paid by this employer during the time you are off work?
Yes No
UI-501 UNEMPLOYMENT APPLICATION PAGE 8 OF 26 MDES: REV-05062020
EMPLOYMENT DETAILS (EMPLOYER #2)
Employer Name: ________________________________________________
Street: _______________________________________________________
City: ____________________________ State: ____________________________
Zip Code: ____________________ Country: ____________________________
1. Did you work for this employer?
YES NO
a. Start Date: _____ - _____ - _____________ b. End Date: _____ - _____ - _____________
c. Job Title/Description: ______________________________________
d. What was your rate of pay? Amount: _____________________
RATE OF PAY: HOURLY DAILY WEEKLY BI MONTHLY MONTHLY YEARLY
e. Reason why you are no longer working with this employer:
LACK OF WORK/LAID OFF DISCHARGE VOLUNTARY QUIT CORONA VIRUS (COVID-19)
LEAVE OF ABSENCE DESIGNATED VACATION STRIKE/LOCKOUT SUSPENSION
i. If Voluntary Quit, select reason:
ATTEND SCHOOL/TRAINING CHILD CARE DISTANCE TO WORK
FAMILY RESPONSIBILITIES HEALTH REASONS MOVE WITH SPOUSE
MOVE WITH SPOUSE-MILITARY NOT PAID CORRECT AMOUNT REDUCED WORK HOURS
RELOCATE START A NEW JOB TO GET MARRIED TRANSPORTATION OTHER
ii. If Discharged/Fired, select reason:
ABSENTEEISM/TARDINESS AWAY FROM WORK STATION DAMAGING COMPANY PROPERTY
FAILED DRUG TEST FALSIFIED DOCUMENTS POOR JOB PERFORMANCE
PHYSICAL ALTERCATION REFUSING TO PERFORM ASSIGNED DUTIES
REFUSING TO WORK OVERTIME SLEEPING ON THE JOB STEALING
SUSPENDED DRIVER’S LICENSE UNAUTHORIZED USE OF COMPANY PROPERTY
UNDER THE INFLUENCE OF ALCOHOL VERBAL ALTERCATION OTHER
f. Are you receiving or are you going to apply for a pension from this employer? YES NO
I. IF YES, PROVIDE THE DATE YOU RECEIVED OR WILL RECEIVE THE PENSION BELOW:
__________ - __________ - ______________________
g. Employer Telephone #: ___________________________________________
h. Are you being paid by this employer during the time you are off work?
Yes No
UI-501 UNEMPLOYMENT APPLICATION PAGE 9 OF 26 MDES: REV-05062020
ADD EMPLOYMENT DETAILS
*REQUIRED INFORMATION
1. *Employer Name: _______________________________________________________
2. *Employer Address Line 1: _______________________________________________________
*Address Line 2: _______________________________________________________
*City: ____________________________ *State: ____________________________
*Zip Code: ____________________ *Country: ____________________________
3. *Start Date: _____ - _____ - _____________ 4. *End Date: _____ - _____ - _____________
5. *Work Location: a. City: ____________________________ b. State: ___________________________
6.. *Job Title/Description _______________________________________________________
7 *What was your rate of pay? Amount: _____________________
*RATE OF PAY: HOURLY DAILY WEEKLY BI MONTHLY MONTHLY YEARLY
8. *Reason why you are no longer working with this employer:
LACK OF WORK/LAID OFF DISCHARGE VOLUNTARY QUIT CORONA VIRUS (COVID-19)
LEAVE OF ABSENCE DESIGNATED VACATION STRIKE/LOCKOUT SUSPENSION
a. If Voluntary Quit, select reason:
ATTEND SCHOOL/TRAINING CHILD CARE DISTANCE TO WORK
FAMILY RESPONSIBILITIES HEALTH REASONS MOVE WITH SPOUSE
MOVE WITH SPOUSE-MILITARY NOT PAID CORRECT AMOUNT REDUCED WORK HOURS
RELOCATE START A NEW JOB TO GET MARRIED TRANSPORTATION OTHER
b. If Discharged/Fired, select reason:
ABSENTEEISM/TARDINESS AWAY FROM WORK STATION DAMAGING COMPANY PROPERTY
FAILED DRUG TEST FALSIFIED DOCUMENTS POOR JOB PERFORMANCE
PHYSICAL ALTERCATION REFUSING TO PERFORM ASSIGNED DUTIES
REFUSING TO WORK OVERTIME SLEEPING ON THE JOB STEALING
SUSPENDED DRIVER’S LICENSE UNAUTHORIZED USE OF COMPANY PROPERTY
UNDER THE INFLUENCE OF ALCOHOL VERBAL ALTERCATION OTHER
9. *Total wages earned since October 1, 2018: ________________________
10. *Are you receiving or are you going to apply for a pension from this employer?
(Do not lnclude severance pay or soclal security benefits.) YES NO
a. IF YES, PROVIDE THE DATE YOU RECEIVED OR WILL RECEIVE THE PENSION BELOW:
__________ - __________ - ______________________
11. *Employer Telephone #: ___________________________________________
12. *Are you being paid by this employer during the time you are off work?
Yes No
UI-501 UNEMPLOYMENT APPLICATION PAGE 10 OF 26 MDES: REV-05062020
APPLICATION FOR RECONSIDERATION OF WAGES
*REQUIRED INFORMATION
1. *Employer Name: _______________________________________________________
2. *Employer Address Line 1: _______________________________________________________
*Address Line 2: _______________________________________________________
*City: ____________________________ *State: ____________________________
*Zip Code: ____________________ *Country: ____________________________
3. *Start Date: _____ - _____ - _____________ 4. *End Date: _____ - _____ - _____________
5. *Owner of the Business: _______________________________________________________
6. *Name/Title of the person who hired you: ________________________________________________
7. *Employer Telephone #: ___________________________________________
8. *FEIN: ________________________________________________
9. *Doing Business As
(MUST NOT EXCEED 100 CHARACTERS)
10. *Nature of employer’s business (MUST NOT EXCEED 250 CHARACTERS)
11. *Directions to the employer’s business (MUST NOT EXCEED 250 CHARACTERS)
UI-501 UNEMPLOYMENT APPLICATION PAGE 11 OF 26 MDES: REV-05062020
12. *Approximately how many people worked for this employer? _____________________
13. *Type of work you performed? ________________________________________________________
14. Work Location: City: ____________________________ State: ____________________________
15. *Were you paid directly by the employer above?
YES NO
a. If No, who paid you? _____________________________________
16. *How were you paid?
CASH CHECK OTHER
17. *Select the document( s) that you received from this employer W-2 1099 OTHER
18. *Did you work under another Social Security Number? YES NO
a. If Yes, provide the other SSN : __________ - ______ - _____________
19. *Enter the quarterly gross wages you earned (including tips, bonuses and commission).
QUARTER/YEAR EMPLOYER REPORTED WAGES ($) CLAIMANT REPORTED WAGES ($)
Oct-Dec 2018
Jan-Mar 2019
Apr-Jun 2019
Jul-Sep 2019
UI-501 UNEMPLOYMENT APPLICATION PAGE 12 OF 26 MDES: REV-05062020
SELF-EMPLOYMENT QUESTIONNAIRE
*REQUIRED INFORMATION
To be ellglble for Unemployment Insurance benefits, you must be
able and available to seek and accept full time work.
1. *Describe your self-employment activities (Must not exceed 1000 characters)
2. *How many hours per week do you spend seeking or performing self-employment?
3. *Are you seeking full-time work other than your self-employment?
Yes No
a. If Yes, what other types of work are you seeking? (Must not exceed 1000 characters)
UI-501 UNEMPLOYMENT APPLICATION PAGE 13 OF 26 MDES: REV-05062020
EMPLOYMENT DETAILS (EMPLOYER #3)
Employer Name: ________________________________________________
Street: _______________________________________________________
City: ____________________________ State: ____________________________
Zip Code: ____________________ Country: ____________________________
1. Did you work for this employer?
YES NO
a. Start Date: _____ - _____ - _____________ b. End Date: _____ - _____ - _____________
c. Job Title/Description: ______________________________________
d. What was your rate of pay? Amount: _____________________
RATE OF PAY: HOURLY DAILY WEEKLY BI MONTHLY MONTHLY YEARLY
e. Reason why you are no longer working with this employer:
LACK OF WORK/LAID OFF DISCHARGE VOLUNTARY QUIT CORONA VIRUS (COVID-19)
LEAVE OF ABSENCE DESIGNATED VACATION STRIKE/LOCKOUT SUSPENSION
i. If Voluntary Quit, select reason:
ATTEND SCHOOL/TRAINING CHILD CARE DISTANCE TO WORK
FAMILY RESPONSIBILITIES HEALTH REASONS MOVE WITH SPOUSE
MOVE WITH SPOUSE-MILITARY NOT PAID CORRECT AMOUNT REDUCED WORK HOURS
RELOCATE START A NEW JOB TO GET MARRIED TRANSPORTATION OTHER
ii. If Discharged/Fired, select reason:
ABSENTEEISM/TARDINESS AWAY FROM WORK STATION DAMAGING COMPANY PROPERTY
FAILED DRUG TEST FALSIFIED DOCUMENTS POOR JOB PERFORMANCE
PHYSICAL ALTERCATION REFUSING TO PERFORM ASSIGNED DUTIES
REFUSING TO WORK OVERTIME SLEEPING ON THE JOB STEALING
SUSPENDED DRIVER’S LICENSE UNAUTHORIZED USE OF COMPANY PROPERTY
UNDER THE INFLUENCE OF ALCOHOL VERBAL ALTERCATION OTHER
f. Are you receiving or are you going to apply for a pension from this employer? YES NO
I. IF YES, PROVIDE THE DATE YOU RECEIVED OR WILL RECEIVE THE PENSION BELOW:
__________ - __________ - ______________________
g. Employer Telephone #: ___________________________________________
h. Are you being paid by this employer during the time you are off work?
Yes No
UI-501 UNEMPLOYMENT APPLICATION PAGE 14 OF 26 MDES: REV-05062020
EMPLOYMENT DETAILS (EMPLOYER #4)
Employer Name: ________________________________________________
Street: _______________________________________________________
City: ____________________________ State: ____________________________
Zip Code: ____________________ Country: ____________________________
1. Did you work for this employer?
YES NO
a. Start Date: _____ - _____ - _____________ b. End Date: _____ - _____ - _____________
c. Job Title/Description: ______________________________________
d. What was your rate of pay? Amount: _____________________
RATE OF PAY: HOURLY DAILY WEEKLY BI MONTHLY MONTHLY YEARLY
e. Reason why you are no longer working with this employer:
LACK OF WORK/LAID OFF DISCHARGE VOLUNTARY QUIT CORONA VIRUS (COVID-19)
LEAVE OF ABSENCE DESIGNATED VACATION STRIKE/LOCKOUT SUSPENSION
i. If Voluntary Quit, select reason:
ATTEND SCHOOL/TRAINING CHILD CARE DISTANCE TO WORK
FAMILY RESPONSIBILITIES HEALTH REASONS MOVE WITH SPOUSE
MOVE WITH SPOUSE-MILITARY NOT PAID CORRECT AMOUNT REDUCED WORK HOURS
RELOCATE START A NEW JOB TO GET MARRIED TRANSPORTATION OTHER
ii. If Discharged/Fired, select reason:
ABSENTEEISM/TARDINESS AWAY FROM WORK STATION DAMAGING COMPANY PROPERTY
FAILED DRUG TEST FALSIFIED DOCUMENTS POOR JOB PERFORMANCE
PHYSICAL ALTERCATION REFUSING TO PERFORM ASSIGNED DUTIES
REFUSING TO WORK OVERTIME SLEEPING ON THE JOB STEALING
SUSPENDED DRIVER’S LICENSE UNAUTHORIZED USE OF COMPANY PROPERTY
UNDER THE INFLUENCE OF ALCOHOL VERBAL ALTERCATION OTHER
f. Are you receiving or are you going to apply for a pension from this employer? YES NO
I. IF YES, PROVIDE THE DATE YOU RECEIVED OR WILL RECEIVE THE PENSION BELOW:
__________ - __________ - ______________________
g. Employer Telephone #: ___________________________________________
h. Are you being paid by this employer during the time you are off work?
Yes No
UI-501 UNEMPLOYMENT APPLICATION PAGE 15 OF 26 MDES: REV-05062020
ABLE AND AVAILABLE DETAILS
1. Are you currently self-employed?
YES NO
2. Have you refused an offer of work since your last day of employment? YES NO
3. Are you presently attending school or training? YES NO
4. Can you accept full-time work immediately? YES NO
If no, why?
5. Are you pregnant? YES NO
If yes, enter your expected delivery date: __________ - __________ - ______________________
TAX WITHOLDING AND PAYMENT OPTION
1. Do you want to have 10% of your Unemployment Insurance Benefits payments, including
Federal Additional Compensation, withheld for Federal Income Tax?
YES NO
UI-501 UNEMPLOYMENT APPLICATION PAGE 16 OF 26 MDES: REV-05062020
LACK OF WORK QUESTIONNAIRE (EMPLOYER #1)
1. When were you told of the lack of work (date)? __________ - __________ - ___________________ .
2. Who told you of the lack of work (name and title)?
_______________________________________
3. Were you given written notice of the lack of work? YES NO
4. Were you the only person laid off? YES NO
5. Were you provided severance pay?
YES NO
6. Select the reason you were told for the lack of work:
REDUCTION IN FORCE CONTINUING WORK NOT AVAILABLE POSITION ELIMINATED
TEMPORARY LAYOFF PINK SLIP CORONA VIRUS (COVID-19) OTHER
a. If other, provide as much detail as possible: Click below to enter text.
UI-501 UNEMPLOYMENT APPLICATION PAGE 17 OF 26 MDES: REV-05062020
LACK OF WORK QUESTIONNAIRE(EMPLOYER #2)
1. When were you told of the lack of work (date)? __________ - __________ - ___________________ .
2. Who told you of the lack of work (name and title)?
_______________________________________
3. Were you given written notice of the lack of work? YES NO
4. Were you the only person laid off? YES NO
5. Were you provided severance pay?
YES NO
6. Select the reason you were told for the lack of work:
REDUCTION IN FORCE CONTINUING WORK NOT AVAILABLE POSITION ELIMINATED
TEMPORARY LAYOFF PINK SLIP CORONA VIRUS (COVID-19) OTHER
a. If other, provide as much detail as possible: Click below to enter text.
UI-501 UNEMPLOYMENT APPLICATION PAGE 18 OF 26 MDES: REV-05062020
LACK OF WORK QUESTIONNAIRE(EMPLOYER #3)
1. When were you told of the lack of work (date)? __________ - __________ - ___________________ .
2. Who told you of the lack of work (name and title)?
_______________________________________
3. Were you given written notice of the lack of work? YES NO
4. Were you the only person laid off? YES NO
5. Were you provided severance pay?
YES NO
6. Select the reason you were told for the lack of work:
REDUCTION IN FORCE CONTINUING WORK NOT AVAILABLE POSITION ELIMINATED
TEMPORARY LAYOFF PINK SLIP CORONA VIRUS (COVID-19) OTHER
a. If other, provide as much detail as possible: Click below to enter text.
UI-501 UNEMPLOYMENT APPLICATION PAGE 19 OF 26 MDES: REV-05062020
LACK OF WORK QUESTIONNAIRE(EMPLOYER #4)
1. When were you told of the lack of work (date)? __________ - __________ - ___________________ .
2. Who told you of the lack of work (name and title)?
_______________________________________
3. Were you given written notice of the lack of work? YES NO
4. Were you the only person laid off? YES NO
5. Were you provided severance pay?
YES NO
6. Select the reason you were told for the lack of work:
REDUCTION IN FORCE CONTINUING WORK NOT AVAILABLE POSITION ELIMINATED
TEMPORARY LAYOFF PINK SLIP CORONA VIRUS (COVID-19) OTHER
a. If other, provide as much detail as possible: Click below to enter text.
UI-501 UNEMPLOYMENT APPLICATION PAGE 20 OF 26 MDES: REV-05062020
ADD MILITARY EMPLOYER
1. Service Branch
ARMY NAVY AIR FORCE MARINES COAST GUARD
2. Service Start Date: __________ - __________ - ___________________ .
3. Service End Date: __________ - __________ - ___________________ .
4. Have you applied for (or) are you receiving a pension from the military?
YES NO
5. Do you have your DD-214 Member 4 copy?
YES NO
Only complete the next page if you have worked
for federal service in the last 18 months
UI-501 UNEMPLOYMENT APPLICATION PAGE 21 OF 26 MDES: REV-05062020
FEDERAL EMPLOYER
1. Federal Agency Name:
_____________________________________________________________
2. Mailing Address: Street: _______________________________________________________
City: ____________________________ State: ____________________________
Zip Code: ____________________ Country: ____________________________
3. Did you receive form SF-8 from this Federal Agency?
YES NO
4. Location of your last Federal employment prior to your separation
City: ____________________ State: ______ Country: ____________________________
5. If you performed Federal Civilian Service outside of the United States, were you
the spouse of a military service member stationed at a military base?
YES NO
6. Employment Start Date: _________ - __________ - _____________________
7. Employment End Date: _________ - __________ - _____________________
8.
Did you perform Federal civilian service while employed with this Federal agency?
YES NO
9. Reason you are no longer working with this employer:
LACK OF WORK/LAID OFF DISCHARGE VOLUNTARY QUIT
LEAVE OF ABSENCE DESIGNATED VACATION STRIKE/LOCKOUT SUSPENSION
I. IF VOLUNTARY QUIT, SELECT REASON:
ATTEND SCHOOL/TRAINING CHILD CARE DISTANCE TO WORK
FAMILY RESPONSIBILITIES HEALTH REASONS MOVE WITH SPOUSE
MOVE WITH SPOUSE-MILITARY NOT PAID CORRECT AMOUNT REDUCED WORK HOURS
RELOCATE START A NEW JOB TO GET MARRIED TRANSPORTATION OTHER
ii. If Discharged/Fired, select reason:
ABSENTEESIM/TARDINESS AWAY FROM WORK STATION DAMAGING COMPANY PROPERTY
FAILED DRUG TEST FALSIFIED DOCUMENTS POOR JOB PERFORMANCE
PHYSICAL ALTERCATION REFUSING TO PERFORM ASSIGNED DUTIES
REFUSING TO WORK OVERTIME SLEEPING ON THE JOB STEALING
SUSPENDED DRIVER’S LICENSE UNAUTHORIZED USE OF COMPANY PROPERTY
UNDER THE INFLUENCE OF ALCOHOL VERBAL ALTERCATION OTHER
UI-501 UNEMPLOYMENT APPLICATION PAGE 22 OF 26 MDES: REV-05062020
10. Have you applied for a pension or, are you receiving a pension from this employer?
YES NO
11. Did you receive or are you entitled to receive severance pay provided by any federal law or
agency-employer agreement?
YES NO
If yes, complete the following
A. WEEKLY AMOUNT ____________________
B. NUMBER OF WEEKS ____________________
C. TOTAL ENTITLEMENT $ ____________________
D. SEVERANCE PAY START DATE: _________ - __________ - _____________________
E. SEVERANCE PAY END DATE: _________ - __________ - _____________________
F. DATE OF PAYMENT: _________ - __________ - _____________________
12. Enter the quarterly gross wages, including tips, bonuses and commission.
These wages will be used to determine your monetary eligibility
Affidavit of Wages
QUARTER/YEAR WAGES
YOU MUST PROVIDE PROOF OF WAGES WITHIN FIVE CALENDAR DAYS OF COMPLETING THIS
APPLICATION. YOU SHOULD UNDERSTAND THAT PENALTIES ARE PROVIDED BY LAW FOR AN INDIVIDUAL
THAT MAKES FALSE STATEMENTS TO OBTAIN BENEFITS. ANY DETERMINATION BASED ON THIS AFFIDAVIT
IS NOT FINAL; DETERMINATIONS ARE SUBJECT TO CORRECTIONS UPON RECEIPT OF WAGES AND
SEPARATION INFORMATION FROM THE FEDERAL AGENCY WHERE YOU WORKED. BENEFIT PAYMENTS
MADE AS A RESULT OF SUCH DETERMINATION MAY HAVE TO BE ADJUSTED ON THE BASIS ON THE
INFORMATION FURNISHED BY THE FEDERAL AGENCY, AND ANY AMOUNT OVERPAID MUST BE REPAID OR
OFFSET AGAINST FUTURE BENEFITS.
YOU MAY RETURN THIS COMPLETED FORM BY EMAIL TO UICLAIMS@MDES.MS.GOV
UI-501 UNEMPLOYMENT APPLICATION PAGE 23 OF 26 MDES: REV-05062020
HOW TO SET UP YOUR ACCOUNT FOR DIRECT DEPOSIT
Go to
WWW.MDES.MS.GOV to set up direct deposit for payment of your Unemployment Benefits:
Select ONLINE UNEMPLOYMENT SERVICES under the UNEMPLOYMENT CLAIMS tab,
and
log in to your account;
Select BENEFITS MAINTENANCE tab;
Select UPDATE CLAIMANT PROFILE tab and then select PAYMENT OPTIONS tab.
Enter the following under PAYMENT OPTIONS:
NAME ON BANK ACCOUNT (referring to the owner of the account)
ACCOUNT TYPE (savings or checking)
BANK ACCOUNT NUMBER
CONFIRM BANK ACCOUNT NUMBER
BANK ROUTING NUMBER
CONFIRM BANK ROUTING NUMBER
PLEASE REVIEW THE INFORMATION ENTERED TO BE SURE IT IS CORRECT TO AVOID DELAY.
DEBIT CARD PROCEDURES
If you have been issued a debit card and it
has not expired, this will be the same card for
receiving your UI benefits.
If you have been issued a debit card within the
past three years and it has been lost, stolen,
or damaged, contact the following number to
request a replacement: 1-866-461-4095. Fees do
apply: $5.00 for normal delivery and the current
$21.00 fee for expedited delivery.
The debit card for UI looks exactly like the debit
card for child support. The only difference is the card for UI has a U printed on the front of the card
on the bottom left. This is how to distinguish the two cards. Funds for UI will not go onto the child
support card.
For a complete list of fees for the debit card, visit https://www.eppicard.com/ and select MS from
the drop down menu. Once you select MS, you will be able to access documents, including the
complete list of fees and disclosure statement.
Check the balance of your card, free of charge, by creating a user ID and password at
https://www.eppicard.com.
UI-501 UNEMPLOYMENT APPLICATION PAGE 24 OF 26 MDES: REV-05062020
HOW TO CREATE AN ACCOUNT
for Online Unemployment Services with
Mississippi Department of Employment Security
Go to WWW.MDES.MS.GOV
Select
ONLINE UNEMPLOYMENT SERVICES
under the UNEMPLOYMENT CLAIMS tab.
On the next screen, click on
CREATE CLAIMANT USER ID.
Provide the information requested on the
NEW USER SIGN UP page.
CREATE your USER ID AND PASSWORD
Passwords must be 8 to 15 characters,
contain at least one uppercase letter, one
lowercase letter, one number and one
symbol (a special character such a !@##”).
UI-501 UNEMPLOYMENT APPLICATION PAGE 25 OF 26 MDES: REV-05062020
INITIAL APPLICATION FOR PANDEMIC UNEMPLOYMENT ASSISTANCE
*REQUIRED INFORMATION
1. *Marital status: MARRIED SINGLE
2. *Number of dependents ____________________
3. *County where you were employed before ________________________________________
4. *County where you lived at the time of disaster? ________________________________________
5. *Last Occupation _____________________________________________________________
6. *Date you became unemployed as a direct result of the disaster
:
_________ - __________ - _____________________
7. Name and Address of Employer
(MUST NOT EXCEED 250 CHARACTERS)
Name: _____________________________________________________________
Mailing Address: Street: _______________________________________________________
City: ____________________________ State: ____________________________
Zip Code: ____________________ Country: ____________________________
Note that your employer will be notified that a claim has been filed and will
be given the opportunity to provide employment and separation information.
8. Do you have a definite date to return to work?
Yes No
a. If yes, enter the date: _________ - __________ - _____________________
UI-501 UNEMPLOYMENT APPLICATION PAGE 26 OF 26 MDES: REV-05062020
INITIAL APPLICATION FOR PANDEMIC UNEMPLOYMENT ASSISTANCE (continued)
*REQUIRED INFORMATION
9. Select the weeks that you were totally or partially unemployed due to the disaster and for which
you are claiming Disaster Unemployment Assistance. Report gross earnings from employment
and net earnings for self employment. The week begins on Sunday and ends on Saturday,
SELECT WEEK ENDING DATE HOURS WORKED EARNINGS ($)
10. Were you able and available for work during each of the weeks selected above? Yes No
11. Did you apply for or receive or would you be eligible to receive if you had applied for:
a. *Unemployment Compensation from another State?
Yes No
State: _______________________ Amount _______________________
b. *Private insurance for illness or disability pay?
Yes No
Type: _______________________ Amount _______________________
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Completed 15 May 2020

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