SOUTH CAROLINA DEPARTMENT OF EMPLOYMENT AND WORKFORCE
MASS SEPARATION TOTAL UNEMPLOYMENT

1.) Employer:       2.) Worker:      
Address:       Social
      Security #:      

Date of
Account#:       Birth:      
Level of Education:       Main Occupation:      
3.) This is to certify the worker named above was separated on       due to
lack of work. (Date)
4.) This worker earned wages in the amount of $       during the week of separation.
5.) Did you pay this worker as much as $2,608? (If “NO,” please enter the amount): $      
Dates of most recent continuous term of employment… From:       To:      
6.) Are you paying, or will you pay, this worker a pension or retirement pay within the next twelve months?
YES NO……If “YES,” what amount are you paying, or will you pay per month, and what is the
effective date of the pension? – FORMTEXT      

a. Please indicate type of retirement:      

b. Did worker contribute to a pension plan? YES NO

c. If “YES,” what percent was contributed by the employer? – FORMTEXT      
7.) Employer’s Signature:       Date:      

(Please Tear Here)

SOUTH CAROLINA DEPARTMENT OF EMPLOYMENT AND WORKFORCE CALL-IN APPOINTMENT NOTICE
Please provide the worker’s name, address, social security
number and telephone number in the spaces below. This
information will be used to schedule the worker to report
to the Workforce Center to file a claim.

Social Security Number:      
Telephone Number:      
Worker:      
Address:      
FAILURE TO REPORT AS INSTRUCTED WILL DELAY BENEFITS
UCB-113
Rev. 6/10
Catalog #: 08180

DO NOT WRITE IN THIS BOX
Information was received indicating you were separated from employment due to
lack of work. In order to file a claim for unemployment insurance benefits, PLEASE
REPORT IN PERSON WITH THIS NOTICE ON THE DATE SCHEDULED
BELOW.

Month Day Year Time

Report to the Workforce Center Shown Below:

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