931 Eta 931

(STATE AGENCY IDENTIFICATION)

REQUEST FOR WAGE AND SEPARATION INFORMATION- UCFE
1. State Agency Address:

3. Local Office/Call Center ID:
Claim:

2. Name of Federal Agency, 3 Digit Agency Code, and Address:

4. Date of Request:

5. Date claim taken:

6. Effective Date of

8. Social Security Number

7. Name (Last, First, Middle Initial)

Complete and Return Within 4 Workdays
9. Location of Official Duty Station. If outside U.S., enter Country: _____________________________
10. Did this person perform Federal Civilian Service,@ as defined for UCFE purposes, for your agency at
any time on or after the base period begin date shown in Item 11a below?
Yes No
If No, Complete Items a – e below.
a. Under what legal authority was the individual hired?__________________________________
b. What funding Source was used for salary payments?
c. Were payroll deductions made for Federal and State taxes?
Yes No
d. Was Employee eligible for:
(1) Annual and Sick leave?
__Yes __No
(2) Health and Life insurance?
__Yes __No
(3) Civil Service or FERS retirement?
__Yes __No
e. Did the Federal agency provide direction and control?
Yes __No
11. Are base period wages provided
electronically?
__Yes __No
If “Yes,” go to Item 12. If “no,” report all
Wages from base period begin date to
separation date.
a. Base period beginning date_________
b. Report wages for quarters ending after
date in “a” above.
# of Weeks # of Hours
Qtr. Ending Worked
Worked Gross
Wages
_________
____
_____ $_______
_________
____
_____ $_______
_________
____
_____ $_______
_________
_ ___
_____ $______
_________
____ _____ $_______
_________
____ _____ $_______
_________
____ _____ $______
_________
____ _____ $______
_________
____ _____ $_______

Print
Name_________________________________
Signature______________________________
ETA- 931 (Revised 1/2003)

12. Separation, Lump Sum Annual Leave, and Severance
Pay
Information
a. Did this person receive payment for annual leave on
or
after the date of separation?
__Yes __No
If ,”Yes” or if currently entitled to such a payment,
enter below:
Amt of payment : $_______ Date of payment:
__/__/__
Number of days of Leave: ___
b. Date of Separation __/__/__
c. Reason for separation:
___________
______________________________________
______________________________________
______________________
______________________________________
___________
d. Did this person receive or is he/she entitled to
receive
severance pay provided by Federal law or agency
employee agreement?
__Yes __No
If “yes,” complete the following information:
Total Amount: $_________
Beginning date: ___/___/____Ending Date:
___/___/____
Title___________________________________________
Telephone Number (_____) ___________________
Date____/___/____

OMB No.: 1205-0179
OMB Expiration Date: XX/XX/XXXX Estimated Average Response Time: 5 Minutes
O M B 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). 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-4231, 200 Constitution Ave., NW, Washington, DC, 20210.

Important Notice
If a completed Form ETA-931 is not received by the 12th calendar day from the “date of request,” the
State agency is authorized by the Department of Labor=s Regulation, published at 20 CFR
609.6(e)(2), to pay benefits to the ex-federal civilian employee based on his/her affidavit. Any benefit
payments made to the claimant will be charged to the Federal employing agency(ies) in accordance
with Section 1023, PL 96-499, Omnibus Reconciliation Act of 1980(94 Stat. 2599).
INSTRUCTIONS TO FEDERAL AGENCY
As an alternative to completing this form, attaching a computer printout that contains all of the
information requested is acceptable if the layout of the print out is cleared with the U.S. Department
of Labor, Washington, DC 20210.
Item 9. Enter the name of the state where the ex-federal civilian employee’s official duty station is
located. If it is outside of the U.S., enter the name of the country.
Item 10. If the federal agency’s response is “No” to this question, provide the information requested
in questions 10 a - e.
Item 11. The state agency will provide the beginning date of the base period for the unemployment
compensation claim filed by the ex-federal civilian employee. All employment and wages from the
base period beginning date through the date of separation are reportable in response to this request.
Enter the number of weeks worked, number of hours worked and gross wages for the current calendar
quarter and all other calendar quarters ending after the base period begin date. Include as wages the
amount of any lump sum annual leave payment. Do not include severance pay as wages (Refer to 5
USC 5595).
Item 12. Agency findings are available from SF 50. If payroll office records are incomplete or
inadequate, or if information on SF-50 is not sufficient, check with personnel for additional
information and add as part of separation information.
Signature of Official. Form is not complete unless it (or attached computer printout) is signed and
dated; also enter signer’s title and telephone number.
ETA 931 (Revised 1/2003)