NOTICE OF POTENTIAL AVAILABILITY OF UNEMPLOYMENT INSURANCE BENEFITS
ATTENTION EMPLOYER: You are legally required to provide a form, in hard copy or electronic format, to an
employee upon separation. Please complete the form using information that matches your employee payroll records.
ATTENTION EMPLOYEE: Below is information from your previous employer at the time of separation from
employment. If you received $2,500 or more in payroll wages from any employer where taxes were withheld in the last
18 months, you may be eligible to file a claim for unemployment benefits. Before you file a claim, gather your income
and related information, such as pay stubs and this form. You can file a claim by visiting the website at
https://cdle.colorado.gov/unemployment or by calling the Unemployment Insurance Division at 303-318-9000 (Denver
Metro) or 1-800-388-5515 (toll free).
Employee Name:
Employee SSN (last four digits only)/ or Individual
Taxpayer Identification Number (ITIN):
Employee Address:
Employee Start Date of Employment:
Employee Last Date Worked:
Employee Year-to-Date Earnings:
Earnings for the Last Week Worked:
Employer Legal Business Name:
Federal Employer Identification Number (FEIN):
Employer Trade Name/Doing Business As Name (if
applicable):
Employer Address:
Reason the employee separated from employment (Please select only one option and limit free-form responses
to one sentence. If an unemployment claim is filed, the Division will reach out to both parties for additional
information about the separation):
Quit
Employee’s reason for quit:________________________________________________________
Layoff
Discharge
Reason for discharge:____________________________________________________________
Other:_________________________________________________________________________
