STATE OF MICHIGAN

UIA 1713 C/E Authorized By

(Rev. 05-19) DEPARTMENT OF LABOR AND ECONOMIC OPPORTUNITY MCL 421.1 et seq.
UNEMPLOYMENT INSURANCE AGENCY
GRETCHEN WHITMER
GOVERNOR
SUSAN R. CORBIN
ACTING DIRECTOR
l
Sent via Go Green

STEVEN M PONTIUS Mail Date: December 23, 2020

1103 MILLARD ST Letter ID: L0083398746
THREE RIVERS MI 49093-9567
CLM: C65057111
Name: STEVEN PONTIUS

Request for Information

Employer Name: HAULMARK TRAILERS OF IN
Social Security Number: ###-##-7852
Benefit Year Begin: March 22, 2020 Case Number: 28827019
A question of eligibility and/or qualification has been raised on a claim in which you are an interested party.
Respond to the questions on the reverse side of this form and keep a copy for your records. Return the completed
form to Unemployment Insurance (UI) by 04-Jan-2021. Failure to respond to this request for information
will result in a determination based on available information.

How to Respond
Submit copies (not the originals) of any records which you believe support your position, such as pay stubs, layoff
slip, federal income tax form, W-2, etc. If you require additional space, attach additional pages(s). Include your
name, Claim ID and Letter ID as shown above, on all documents that you submit.

You can respond online, by mail or fax. To submit your response through your MiWAM account, go to
www.michigan.gov/uia and select "Additional fact finding is required for your claim." If you do not have an existing
MiWAM account, you can create an account by selecting "Register as a New User", and follow the prompts. To
respond by mail, return the completed form along with a copy of any additional documents to Unemployment
Insurance Agency, P.O. Box 169, Grand Rapids, MI 49501-0169 or fax to (517) 636-0427.

Penalties
It is against state law to intentionally make false statements or conceal material information to gain or avoid the
payment of benefits. You may have to repay up to 1.5 times the amount of benefits received. Benefits will be
stopped, and any remaining benefits will be lost. You may also be subject to criminal prosecution. If prosecuted,
you may be required to pay court costs and fines, face jail time, perform community service or any combination of
these.

If your address changes it is important to update it with Unemployment Insurance.

If you have questions, contact UIA Customer Service at 1-866-500-0017. TTY customers use 1-866-366-0004.

1 UIA is an Equal Opportunity Employer/Program.

l Auxiliary aids, services and other reasonable

accommodations are available upon request to
individuals with disabilities.
UIA 1713 C/E Letter ID: L0083398746
(Rev. 05-19)

Additional information is necessary regarding Working Full Time.

False

Are you working?

Yes No

Are you working full time?

Yes No

How many hours are you working per week?

_____________________________________________

What date did you start working these hours?

____________________

Have you stopped working full time?

Yes No

What date did you stop working full time?

____________________

Additional information is necessary regarding Earned Income of $0.00.

Benefit Weeks Paid Employer Report of Earnings Claimant Report of Earnings Hours Worked

17-Oct-2020 ________________________ ________________________ ___________

24-Oct-2020 ________________________ ________________________ ___________

31-Oct-2020 ________________________ ________________________ ___________

07-Nov-2020 ________________________ ________________________ ___________

Certification: I certify that the information I have reported is true and correct. I understand that if I intentionally
make a false statement, misrepresent facts or conceal material information to reduce or prevent benefits, I may be
required to repay benefits, charged damages and could be subject to criminal prosecution.
______________________________________________ _____________________ ______________________________
Signature Date Telephone Number
_______________________________________________ ____________________________________________________________
Print Name Title

1
UIA is an Equal Opportunity Employer/Program.
Auxiliary aids, services and other reasonable

l accommodations are available upon request to

individuals with disabilities.
UIA 1713 C/E Letter ID: L0083398746
(Rev. 05-19)

14-Nov-2020 ________________________ ________________________ ___________

21-Nov-2020 ________________________ ________________________ ___________

28-Nov-2020 ________________________ ________________________ ___________

05-Dec-2020 ________________________ ________________________ ___________

12-Dec-2020 ________________________ ________________________ ___________

Certification: I certify that the information I have reported is true and correct. I understand that if I intentionally
make a false statement, misrepresent facts or conceal material information to reduce or prevent benefits, I may be
required to repay benefits, charged damages and could be subject to criminal prosecution.
______________________________________________ _____________________ ______________________________
Signature Date Telephone Number
_______________________________________________ ____________________________________________________________
Print Name Title

1
UIA is an Equal Opportunity Employer/Program.
Auxiliary aids, services and other reasonable

l accommodations are available upon request to

individuals with disabilities.
UIA 1713 C/E Letter ID: L0083398746
(Rev. 05-19)

English
IMPORTANT! This document(s) contains important information about your unemployment compensation rights,
responsibilities and/or benefits. It is critical that you understand the information in this document.

IMMEDIATELY: If needed, call 1-866-500-0017 for assistance in the translation and understanding of the information
in the document(s) you have received.

Spanish
¡IMPORTANTE! Este documento (s) contiene información importante sobre sus derechos, responsabilidades y / o
beneficios de compensación de desempleo. Es fundamental que comprenda la información de este documento.

INMEDIATAMENTE: Si es necesario, llame al 1-866-500-0017 para obtener ayuda en la traducción y

comprensión de la información en el (los) documento (s) que ha recibido.

Arabic

Albanian
• E RËNDËSISHME! Ky dokument përmban informacione të rëndësishme për të drejtat, përgjegjësitë dhe / ose
përfitimet e kompensimit të papunësisë. Është e rëndësishme që ju të kuptoni informacionin në këtë dokument.
• MENJËHERË: Nëse është e nevojshme, telefononi 1-866-500-0017 për ndihmë në përkthimin dhe kuptimin
e informacionit në dokumentet që keni marrë.