Unemployment Insurance Eligibility Questionnaire
Important: You must answer the questions on this form and give it to the New York State Department of Labor upon
request. We use your answers to help decide if you are eligible for Unemployment Insurance benefits and to give us an
idea of what your prospects are for finding another job.
In order to receive Unemployment Insurance benefits, you must be ready, willing and able to work. You must be
actively seeking work in a sustained and systematic manner and be willing to accept work that you are suited for by
training and/or experience. You must also keep and complete a work search record (online or written) for each week
you claim Unemployment Insurance benefits. You must provide a copy of your written record to the Department of
Labor upon request.
Your Name (First and Last):
Last four (4) digits of your Social Security Number: XXX-XX- __ __ __ __
1. Are you ready, willing, and able to work? Yes No If “No,” explain:
___________________________________________________________________________________________
2. Can you start work immediately? Yes No If “No,” explain:
3. Are you actively seeking work? Yes No
a. What job titles are you seeking?
b. Are you maintaining a work search record? Yes No
4. What hours are you willing to work? From: AM PM To : AM PM
5. What shif ts are you willing to work? 1st 2nd 3rd All
6. What is the lowest wage you will accept for this kind of work? $ Per:
7. Check the days of the week you are willing to do this kind of work:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8. You must be willing to travel a reasonable distance to get to work. Generally, a ‘reasonable distance of travel,’
one way, is one hour by private transportation or one-and-one-half hours by public transportation.
Are you willing to travel one hour, if you are using private transportation, and one-and-one-half
hours, if you are using public transportation, to get to work? Yes No
9. Are you attending school? Yes No
10. While claiming benefits, have you done or are you doing any service for a friend or
relative’s business, either with or without pay? Yes No
11. Are you receiving, or have you applied for Workers’ Compensation or disability benefits? Yes No
12. Are you receiving, or have you applied for any pension or Social Security benefits? Yes No
If yes, do you limit yourself to the type of work, hours or days of work, or amount of earnings
that you would accept because you are receiving these benefits? Yes No
I certify the above information regarding my eligibility for Unemployment Insurance benefits is true to the best of my
knowledge and I understand that there are legal penalties for making false statements. I understand that I must
promptly report any changes in the information given on this questionnaire. I understand that if I do not comply with
these conditions, I may not be eligible to receive Unemployment Insurance benefits.
Customer Signature: Date:
WS 1 (01/21)
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