NOTICE OF SEPARATION OR REFUSAL OF WORK UNDER CONDITIONS THAT MAY DISQUALIFY  60-0154 (09-20 61 )       Instructions On Reverse
 WORKER’S NAME                                                        SOCIAL SECURITY NUMBER                                       (Date) Separation or refusal to work
                                                                                                                                     Month                Day      Year

EMPLOYMENT WAS TERMINATED FOR THE REASON CHECKED
                                                                        Voluntary           Discharged for                            Refused                 Left
                                                                       Quit
The Protest Box and Complete Separation or Refusal of Work Date                             Misconduct in                            Suitable Work            to take
MUST BE INDICATED on all responses.  .  .  .  .  .  .  .  .  .  .  .  
                                                                                            Connection With                          or Recall                other
                                                                                            Work                                     To Work                  employment

IOWA ACCOUNT NUMBER           If Applicable, Location Code                                          INTERVIEW INFORMATION
                                                                       If a fact-finding interview is necessary, you will be scheduled for an interview by telephone unless it is 
                                                                       impractical to do so.
EMPLOYER
                                                                       NAME OF PERSON who will participate in a fact-finding interview for this employer. 
                                                                       PRINT LEGIBLY
                                                                       Name_____________________________________________________________________________
                                                                       Title______________________________________________________________________________
EMPLOYER ADDRESS (Street, City, State and Zip Code)                    Telephone number for fact-finding interview 
                                                                       __________________________________________________________________________________
                                                                       (Area Code)                                      Phone Number
                                                                       SUPPORTING DOCUMENTS may be submitted with this form for consideration at the telephone 
                                                                       fact-finding. The separation information you provide must be Certified Correct By Signing and 
                                                                       Completing the Signature Box.
                                                                       CERTIFIED CORRECT BY (Signature Required) __________________________________

                                                                      TITLE _____________________________________                    Date ____________

FOR DEPARTMENT USE ONLY:      O.C. ________________________L.O.# ____________________________

NOTICE OF SEPARATION OR REFUSAL OF WORK UNDER CONDITIONS THAT MAY DISQUALIFY  60-0154 (09-20 61 )       Instructions On Reverse
 WORKER’S NAME                                                        SOCIAL SECURITY NUMBER                                       (Date) Separation or refusal to work
                                                                                                                                     Month                Day      Year

EMPLOYMENT WAS TERMINATED FOR THE REASON CHECKED
                                                                        Voluntary           Discharged for                            Refused                 Left
                                                                       Quit
The Protest Box and Complete Separation or Refusal of Work Date                             Misconduct in                            Suitable Work            to take
MUST BE INDICATED on all responses.  .  .  .  .  .  .  .  .  .  .  .  
                                                                                            Connection With                          or Recall                other
                                                                                            Work                                     To Work                  employment

IOWA ACCOUNT NUMBER           If Applicable, Location Code                                          INTERVIEW INFORMATION
                                                                       If a fact-finding interview is necessary, you will be scheduled for an interview by telephone unless it is 
                                                                       impractical to do so.
EMPLOYER
                                                                       NAME OF PERSON who will participate in a fact-finding interview for this employer. 
                                                                       PRINT LEGIBLY
                                                                       Name_____________________________________________________________________________
                                                                       Title______________________________________________________________________________
EMPLOYER ADDRESS (Street, City, State and Zip Code)                    Telephone number for fact-finding interview 
                                                                       __________________________________________________________________________________
                                                                       (Area Code)                                      Phone Number
                                                                       SUPPORTING DOCUMENTS may be submitted with this form for consideration at the telephone 
                                                                       fact-finding. The separation information you provide must be Certified Correct By Signing and 
                                                                       Completing the Signature Box.
                                                                       CERTIFIED CORRECT BY (Signature Required) __________________________________

                                                                      TITLE _____________________________________                    Date ____________

FOR DEPARTMENT USE ONLY:      O.C. ________________________L.O.# ____________________________

                 IOWA WORKFORCE DEVELOPMENT
                                                P.O. Box 10331
                                                Des Moines, Iowa 50306

                                                INSTRUCTIONS TO EMPLOYER

Whenever a worker leaves or refuses your employment for any reason that you believe disqualifies the individual from receiving 
unemployment insurance benefits, you should notify IOWA WORKFORCE DEVELOPMENT by completing this Notice of Separation 
form, 60-0154. The Notice of Separation can also be filed online at https://uiclaims.iwd.iowa.gov/EmployerSeparation. If you 
provide the information online, you do not need to send a paper copy of this form.

THE ORIGINAL COPY of this form must be postmarked or received by Iowa Workforce Development within ten days from the date 
of the notice of claim. You may keep a duplicate copy of the form for your file.

DO NOT use this form if the worker was laid off for lack of work, regardless of whether the work was permanent or temporary.

IF A WORKER FILES an unemployment insurance claim, you will receive notice of that filing by a Notice of Claim or through the 
scheduling of a fact-finding interview with you and the claimant.

IF A CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS IS FILED, IOWA WORKFORCE DEVELOPMENT will schedule a fact-
finding interview and take the statements from both the worker and the employer. A decision will then be made regarding the worker’s 
eligibility for unemployment insurance benefits.

                 IOWA WORKFORCE DEVELOPMENT
                                                P.O. Box 10331
                                                Des Moines, Iowa 50306

                                                INSTRUCTIONS TO EMPLOYER

Whenever a worker leaves or refuses your employment for any reason that you believe disqualifies the individual from receiving 
unemployment insurance benefits, you should notify IOWA WORKFORCE DEVELOPMENT by completing this Notice of Separation 
form, 60-0154. The Notice of Separation can also be filed online at https://uiclaims.iwd.iowa.gov/EmployerSeparation.  If you 
provide the information online, you do not need to send a paper copy of this form.

THE ORIGINAL COPY of this form must be postmarked or received by Iowa Workforce Development within ten days from the date 
of the notice of claim. You may keep a duplicate copy of the form for your file.

DO NOT use this form if the worker was laid off for lack of work, regardless of whether the work was permanent or temporary.

IF A WORKER FILES an unemployment insurance claim, you will receive notice of that filing by a Notice of Claim or through the 
scheduling of a fact-finding interview with you and the claimant.

IF A CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS IS FILED, IOWA WORKFORCE DEVELOPMENT will schedule a fact-
finding interview and take the statements from both the worker and the employer. A decision will then be made regarding the worker’s 
eligibility for unemployment insurance benefits.