Colorado Unemployment Insurance Internet Claims Filing System CubLine Online (Continued Claims) Application

Social Security: XXX-XX-8113 Today is 1/1/2012 9:45:55 PM (MT)

Your Continued Claim Has Been Received.

Your Confirmation Number is 8373488.

We suggest you print a copy for your own records. Click here for follow-up information and links to other unemployment related sites and forms.

Please review all information listed below. Corrections CANNOT be made from this screen. If you find substantial errors, please send your corrections to us. You may fax it to 303-318-9014 or mail it to PO Box 400, Denver, CO 80201. Please include your name, telephone number, confirmation number and Social Security Number on your correspondence.

ATTENTION NEW SERVICE OFFERING My UI Claimant

The MyUI Claimant Web site is a quick and easy way to get information about your claim online. No more long waits on the phone.

To Establish an AccountGo to www.colorado.gov/MyUIClaimant, and follow

the instructions.

Introduction You must respond to all questions and submit your request. Incomplete applications are not accepted. Exiting before submitting the application will cause any information you entered to be lost. You are responsible for the accuracy of all your answers.

NOTE: Intentionally submitting false information is a criminal act and will be prosecuted.

You are filing a UI continued claim (request for payment). The choice to file a request for payment of UI benefits at this time is entirely yours. All information and responses you provide regarding the weeks claimed are used in determining your eligibility for payment.

You can be charged with fraud if you provide false information or use a false social security number when filing your claim.

UI benefit payments are issued either to your personal Colorado Automated Payment (CAP) Card, a Visa debit card issued by the Colorado Department of Labor and Employment (CDLE) through its agent, Chase Bank, or by direct deposit into a checking or savings account of your choice.

Your CAP Card account is created when you file a UI claim. Within one week after filing your UI claim, you will receive in the mail your CAP Card and enrollment information in a plain, white envelope from Chase. Carefully read all the CAP Card information you receive. Go to www.colorado.gov/cdle/ui for more information.

For questions about your CAP Card account, contact Chase Customer Service at 1-866-316-3925 (toll free) or visit their Web site at

www.myaccount.chase.com. The UI Operations Customer Contact Center cannot answer questions about your CAP Card account.

From the Payment Selection Web page, you may change between direct deposit and the CAP Card as your preferred payment method at any time. Provided you are eligible for payment, the UI Program deposits your entire UI benefit payment to the payment method of choice on file as of 5:30 p.m. on the day you contact CUBLine Online or CUBLine to request payment. I have read and understand all of the above statements.

Enter your Social Security Number. Enter as #########: XXXXX8113

Enter your personal identification number (PIN). (Enter as ####): ****

Initial Questionnaire - Week Ending 12/24/2011 During this week, did you look for a job? Yes

During this week, if an employer offered you a job were you able to start immediately? Yes

During this week, did you turn down any job offers? No

During this week, did you work at all?

Yes

During this week, did you stop working for any employer? No

During this week, did any employer pay you any money such as severance, vacation, 401K, pension, or other payments besides wages? Select "No" if you already told us about the payment. No

During this week, did you receive a payment for prior commission sales? No

I understand that giving false information constitutes fraud and is punishable by law. Yes

I have reviewed my responses and want to continue. Yes

Paid Work - Week Ending 12/24/2011 How many hours did you work from Sunday to Saturday? 3

How much were you paid or how much will you be paid? ($$$$.$$) 200.00

Initial Questionnaire - Week Ending 12/31/2011 During this week, did you look for a job? Yes

During this week, if an employer offered you a job were you able to start immediately? Yes

During this week, did you turn down any job offers? No

During this week, did you work at all? Yes

During this week, did you stop working for any employer? No

During this week, did any employer pay you any money such as severance, vacation, 401K, pension, or other payments besides wages? Select "No" if you already told us about the payment. No

During this week, did you receive a payment for prior commission sales? No

I understand that giving false information constitutes fraud and is punishable by law. Yes

I have reviewed my responses and want to continue. Yes

Paid Work - Week Ending 12/31/2011 How many hours did you work from Sunday to Saturday? 3

How much were you paid or how much will you be paid? ($$$$.$$) 200.00

REMINDERS AND CERTIFICATION You must file a payment request (continued claim) every two weeks in order to receive payment.

You are scheduled to file your next continued claim between Sunday 1/15/2012, and Saturday, 1/28/2012, and once every two weeks after that if you remain unemployed.

Additional information can be submitted in one of the following ways:

Fax to 303-318-9014 Mail to PO Box 400, Denver, CO 80201. NOTE: You must include your name and social security number on each page of additional information that is sent to us.

If additional information is needed by UI Operations to resolve any issues, a customer-service representative will contact you.

Visit the Colorado Department of Labor and Employment Unemployment Benefits home page to view Your Guide to Unemployment and Getting Paid. Go to www.colorado.gov/cdle/ui. Click on Forms & Publications, Worker Publications.

CERTIFICATION AGREEMENT I certify that all information submitted at this web site is true and correct. I understand that knowingly making a false statement or withholding information is an act of fraud that could result in civil and criminal prosecution, including court costs, fines, and/or imprisonment.

I understand that:

If I work during any week for which I am claiming UI benefits, I must report all gross earnings in the week earned regardless of whether or not I have been paid. In order to receive payment, I must file a biweekly continued claim on a timely basis. Failure to comply with any of these requirements may result in a denial of UI benefits. I hereby apply for UI benefits and request UI Operations to determine the amount of UI benefits that I will be eligible to receive if I meet all the eligibility requirements of the law.

Yes, I want to file a continued claim for payment.