UNEMPLOYMENT INSURANCE TERMINATION REPORT Clear Form

Clear Form
UNEMPLOYMENT INSURANCE TERMINATION REPORT
Forward to your local Unemployment
Insurance Coordinator
U5602 (R8/12) University of California Human Resources
To be completed by the department(s) for all separating employees.
Please print or type and complete all items accurately. Failure to do so may subject the University to a penalty. Send completed form directly to the
Unemployment Insurance Coordinator, local Personnel Office. Do not route with other separation forms. Delay in submission could affect benefits.
PERSONAL INFORMATION
NAME (Last, First, Middle Initial)
CAMPUS
DEPARTMENT NAMES
SOCIAL SECURITY NUMBER
EMPLOYEE ID NUMBER
DATE OF SEPARATION
DATE OF HIRE
LAST DAY ACTUALLY WORKED
U.C. STUDENT STATUS
FULL ACCOUNTING UNIT(S)
PAYROLL TITLES
TITLE CODES AT SEPARATION
Not Registered
Undergraduate
Graduate
Other
PRIMARY FUNDING SOURCE (Check only one box)
19900 Funds
Federal Funds
Hospital Funds
All other funds
REASON FOR TERMINATION (This question must be answered accurately in all cases.)
Was termination requested or suggested by the University?
Yes
No
REASON FOR SEPARATION Provide details in “Explanation” below.
Resignation
(AA) To accept another job*
(AB) To look for another job
(AC) Self-employment
(AD) Dissatisfied with job
(AE) Pregnancy–did not desire leave
(AF) Family and/or child care
(AG) Health
(AH) To attend school
Retirement
(AI) Military Service
(AJ) Failed to return from leave
(AK) Other (explain below)
Expiration of Appointment
(RA) Retirement
(RD) Retirement—compulsory for SMGs and regents’ officers
(RF) Retirement—faculty
Release
(BA) Grant/contract expired
(BB) Appointment/contract appt. expired
(BC) Visa/work authorization expired
Indefinite Layoff
(AM) Moved out of area
(AN) No reason given
(EC) Quit without notice
(CB) Limited employee
(CC) Other casual employee (on call)
(CD) Casual restricted appointment
(CE) Graduation/no longer student
(CF) Per diem release
Termination—Due to:
(CA) Layoff w/recall/rehire rights
(CG) Layoff w/severance
Medical Separation
(CH) Layoff, severance & rehire/recall rights
(CI) Layoff, no severance or recall
Change to Emeritus Status
(GA)
(JA)
Death
(EA) Lack of performance
(ED) Job abandonment
(EF) No longer certified/licensed
Released—Before attaining regular status
(DA)
(EB) Misconduct
(EE) Never started employment
(EG) Do not rehire—settlement
(employee agrees not to return)
Intercampus Transfer
(IT)
Termination from Senior Management and Coach/Related Professional
(KA) Give date and name of survivor
(LA) Other termination
Explanation:
*If resigning to accept other employment, provide name of next employer ______________________________________________________
Layoff/Furlough
(MO/DY/YR)
(MO/DY/YR)
Temporary Layoff
Give dates:
From_______________________ To___________________________
Furlough
Give dates:
From_______________________ To___________________________
SIGNATURES
EMPLOYEE RETN: 3 years after separation
Other copies: 0–3 years after separation
DATE
DEPARTMENT HEAD
DATE
PREPARED BY
DATE EXTENSION
For Unemployment Insurance records only. Not for use in employment references.
SEE PAGE 2 FOR PRIVACY NOTIFICATIONS
Clear Form
TO BE COMPLETED BY EMPLOYEE
NOTICE OF RESIGNATION
TO:
Department Head
Date:__________________
(MO/DY/YR)
_______________________________________ Department
_______________________________________ Campus
I hereby submit my resignation as an employee of the University of California, effective ____________________________________________
(MO/DY/YR)
My reason(s) is (are) as follows: _______________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Name and city of my next employer (if leaving for other employment)__________________________________________________________
________________________________________________________________________________________________________________
Please forward all communications to me at the following address:
ADDRESS (Number, Street, P.O. Box)
(City, State, ZIP, Country)
PLEASE PRINT NAME
SIGNATURE
Print Form
PRIVACY NOTIFICATIONS
STATE
The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the University to provide the following information to individuals who are
asked to supply information about themselves.
The principal purpose for requesting information on this form, including your Social Security number, is to verify your identity, and/or for benefits administration,
and/or for federal and state income tax reporting. University policy and state and federal statutes authorize the maintenance of this information.
Furnishing all information requested on this form is mandatory. Failure to provide such information will delay or may even prevent completion of the action for
which the form is being filled out. Information furnished on this form may be transmitted to the federal and state governments when required by law.
Individuals have the right to review their own records in accordance with University personnel policy and collective bargaining agreements. Information on
applicable policies and agreements can be obtained from campus or Office of the President Staff and Academic Personnel Offices.
The official responsible for maintaining the information contained on this form is the Vice President—University of California Human Resources, 1111 Franklin
Street, Oakland, CA 94607-5200.
FEDERAL
Pursuant to the Federal Privacy Act of 1974, you are hereby notified that disclosure of your Social Security number is mandatory. The University’s record keeping
system was established prior to January 1, 1975 under the authority of The Regents of the University of California under Article 1X, Section 9 of the California
Constitution. The principal uses of your Social Security number shall be for state tax and federal income tax (under Internal Revenue Code sections 6011.6051
and 6059) reporting, and/or for benefits administration, and/or to verify your identity.
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