Facsimile of Form ETA 9129 w-track changes

Facsimile of Form

ETA 9129 REEMPLOYMENT AND ELIGIBILITY ASSESSMENT OUTCOMES

STATE:

REGION:

REPORT FOR PERIOD ENDING:

1. Claimants in the State-Defined Comparison Group
a.	Number Who Established a UI Benefit Year in the Report Quarter
b.	Total Weeks Compensated
c.	Total Benefits Paid
d.	Number of Disqualifications
e.	Number Exhausting Benefits
f.	Number Reemployed Within the Benefit Year
g.	Average Number of Weeks to Date of Reemployment
h.	Amount of Overpayments Established
2. Claimants Scheduled for at Least one REA During their Benefit Year
a.	Number Who Established a UI Benefit Year in the Report Quarter
b.	Total Weeks Compensated
c.	Total Benefits Paid
d.	Number of Disqualifications
e.	Number Exhausting
f.	Number Reemployed Within the Benefit Year
g.	Average Number of Weeks to Date of Reemployment
h.	Amount of Overpayments Established

Comments:

OMB No.: 1205-0456 OMB Expiration Date: 01/31/2016 OMB Burden Hours: 30 Minutes

OMB Burden Statement: These reporting instructions have been approved under the Paperwork reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a valid OMB control number. Public reporting burden for this collection of information includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Submission is required to obtain or retain benefits under SSA 303(a)(6). Respondents have no expectation of confidentiality. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workforce Security, Room S-4524, 200 Constitution Ave., NW, Washington, DC, 20210.