SSN: ________   LOC: ________   Mail Date: ________

Your claim for Unemployment Insurance benefits for the week ending ____________,
was filed using the Automated Voice Response System. We need to have more detailed
information about your job contacts for our work search verification process.

PLEASE PROVIDE THE INFORMATION REQUESTED BELOW AND MAIL IT BACK IN THE ENCLOSED ENVELOPE NO LATER THAN ____________.
FAILURE TO COMPLETE AND RETURN THIS LETTER MAY AFFECT YOUR ELIGIBILITY FOR BENEFITS.

Please provide the requested information concerning your job search for the week of ____________ through ____________.
Date of Contact  Company Name and Complete Mailing Address  Phone Number  Person Contacted  Type of Position  Result of Contact  Method of Contact
  Hired
  Interviewed
  None
  In-person
  Telephone
  Internet/Email
  U.S. Mail
  Fax
  Hired
  Interviewed
  None
  In-person
  Telephone
  Internet/Email
  U.S. Mail
  Fax
  Hired
  Interviewed
  None
  In-person
  Telephone
  Internet/Email
  U.S. Mail
  Fax
NOTE: If you have no detailed information, check here .
If no contacts were made, list the reasons on the back of this letter.

If you have any questions concerning this form, please call (866) 832-2363.

Please sign and date below to certify that the statements made above concerning your work search activities are accurate and complete.


I certify that the statements made in connection with this claim are true to the best of my knowledge. I understand that knowingly providing false or misleading information or withholding material information constitutes a Class 1 misdemeanor that could result in a fine, a jail sentence, or both. In addition, I understand that I will be liable for a 15% penalty on any amount of benefits erroneously paid due to my providing false or misleading information to obtain benefits.

Signature__________________________   Date__________________________

Please use the enclosed envelope to return this form.

The Virginia Employment Commission is an equal opportunity employer/program.
Auxiliary aids and services are available upon request to individuals with disabilities.
Telecommunications Device for the Deaf 1-500-825-1120
VEC-B-36 (Revised 8-2013)