| LOCATION |
FIELD |
LENGTH |
DESCRIPTION & REMARKS |
| 1-9 |
Social Security Number |
09 |
Claimant's complete 9 digit Social Security
Number |
| 10-36 |
Claimant's Name |
27 |
Last Name/First Name Middle Initial (If
Jr, Sr, III, etc., Last Name Jr/First Name Middle Initial) |
| 37-66 |
Claimant's Street Address |
30 |
Claimant's Mailing Address |
| 67-86 |
Claimant's City |
20 |
City Name of Claimant's Address |
| 87-88 |
Claimant's State |
02 |
State Name Abbreviation of Claimant's
Address |
| 89-93 |
Claimant's Zip Code |
05 |
5 Digit Zip code of Claimant's Address |
| 94 |
Citizen |
01 |
Is Claimant an American Citizen?
1 = Yes
2 = No |
| 95-104 |
Permit Number |
10 |
If Claimant is NOT American Citizen,
Green Card Number. Leave blank if Claimant IS American citizen. |
| 105-106 |
Out of State |
02 |
If Claimant has out of State wages, enter
the State name abbreviation. Leave BLANK if Claimant has NO out
of State wages. |
| 107 |
Ethnicity |
01 |
Claimant's Ethnicity?
1 = Non-Hispanic
2 = Hispanic
3 = Information not available |
| 108 |
Race |
01 |
Claimant's Race?
0 = Information not available
1 = White
2 = Black
3 = Native Hawaiian/Other Pacific Islander
4 = American Indian/Alaskan Native
5 = Asian |
| 109 |
Gender |
01 |
Claimant's Gender?
1 = Male
2 = Female |
| 110 |
Disabled |
01 |
Claimant Disabled?
1 = Yes
2 = No |
| 111-116 |
Week Ending Date |
06 |
End of Payroll week for which Payment is Requested.
Numeric - Format MMDDYY |
| 117-123 |
Earnings Amount |
07 |
Gross Total Earnings for the Week for Which Payment
is Requested.
Numeric - Enter Dollars and Cents with No Punctuation and Padded with leading Zeros. If nothing
to report, zero fill. |
| 124-130 |
Holiday Pay Amount |
07 |
Gross Total Holiday Pay for the Week for Which
Payment is Requested.
Numeric - Enter Dollars and Cents with No Punctuation and Padded with leading Zeros. If nothing
to report, zero fill. |
| 131-137 |
Vacation Pay Amount |
07 |
Gross Total Vacation Pay for the Week for Which
Payment is Requested.
Numeric - Enter Dollars and Cents with No Punctuation and Padded with leading Zeros. If nothing
to report, zero fill. |
| 138-144 |
Other Pay Amount |
07 |
Gross Total Wages Earned with Another Employer
for the Week for Which Payment is Requested.
Numeric - Enter Dollars and Cents with No Punctuation and Padded with leading Zeros. If nothing
to report, zero fill. |
| 145 |
Federal Withholding |
01 |
1= Yes
2 = No |
| 146-155 |
Employer Account # |
10 |
10 Digit DIR Tax Number |
| 156-161 |
Last Date Worked |
06 |
MMDDYY Numeric |
| 162-171 |
Claimant's Phone # |
10 |
Numeric. Zero fill if not available |
| 172-177 |
Claimant's Birthday |
06 |
MMDDYY Numeric |
| 178-202 |
Employer Contact Person |
25 |
First Name Last Name |
| 203-212 |
Contact Person's Phone # |
10 |
Complete Phone Number, include area code. NO
PUNCTUATION |
| 213 |
Blank |
01 |
Reserved for future use. |
| 214-219 |
Entry Date |
06 |
Date Record Sent to DIR.
MMDDYY Numeric |
| 220-231 |
Blanks |
12 |
Reserved for future use. |
| 232 |
Name Change |
01 |
Y = Yes
N = No |
| 233-237 |
Blank |
05 |
Reserved. |
| 238 |
Address Change |
01 |
1= Yes
2 = No |
| 239-262 |
Blank |
24 |
Reserved. |
| 263 |
Direct Deposit Indicator |
01 |
Y = Yes
N = No
If Claimant's elects for Direct Deposit = Y Else N
|
| 264 |
Direct Deposit Type |
01 |
1= Checking
2 = Savings 3 = Debit Card If Direct Deposit = N.
Then Debit Card is selected by default.
Else select a Direct Deposit type.
|
| 265-281 |
Account Number |
17 |
Enter the bank Account Number(numeric).
If Direct Deposit = N, Zero fill. |
| 282-290 |
Routing Number |
09 |
Enter the nine digit bank Routing Number(numeric).
If Direct Deposit = N, Zero fill. |
| 291 |
Veteran |
01 |
1= Yes
2 = No |
| 292-294 |
Education |
03 |
Select the Highest grade level completed 0-19. |
| 295-329 |
Occupation |
35 |
If Available, Job Title/Description. |
| 330-337 |
Blank |
08 |
Reserved |