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NC DEPT. OF COMMERCE DIVISION OF EMPLOYMENT SECURITY UNEMPLOYMENT INSURANCE POST OFFICE BOX 25903 RALEIGH NORTH CAROLINA 27611 FAX NUMBER Notice of Unemployment Claim Wages Reported and Potential Charges E DATE EAN SSN PL CLAIMANT NAME BENEFIT YEAR BEGAN M You are the claimant s LAST employer as well as a base period employer. This form is to notify you of the potential charges to your account and it cannot be used to request non-charging. The determination to be charged or not be charged will be based on the reason for separation that you provide on form NCUI-500AB Request for Separation Information* Failure to respond timely to Form NCUI-500AB may result in the claimant receiving benefits and your account being charged* In order to receive non-charging if the claimant was discharged within 100 days for inability to perform work you must respond timely to form NCUI-500AB Request for Separation information* WEEKLY BENEFIT AMOUNT SA PERCENT OF TOTAL EARNINGS ALLOWANCE BASE PERIOD WAGES MAXIMUM POTENTIAL CHARGES WAGES BY QUARTER QTY/YR THIS FORM SHOULD BE RETURNED TO THE ABOVE ADDRESS OR FAX NUMBER SHOWN ABOVE WITHIN 15 DAYS ONLY IF THIS CLAIMANT DID NOT WORK FOR YOU OR IF THE BASE PERIOD WAGES ARE INCORRECT. This form is to notify you of the potential charges to your account and it cannot be used to request non-charging. The determination to be charged or not be charged will be based on the reason for separation that you provide on form NCUI-500AB Request for Separation Information* Failure to respond timely to Form NCUI-500AB may result in the claimant receiving benefits and your account being charged* In order to receive non-charging if the claimant was discharged within 100 days for inability to perform work you must respond timely to form NCUI-500AB Request for Separation information* WEEKLY BENEFIT AMOUNT SA PERCENT OF TOTAL EARNINGS ALLOWANCE BASE PERIOD WAGES MAXIMUM POTENTIAL CHARGES WAGES BY QUARTER QTY/YR THIS FORM SHOULD BE RETURNED TO THE ABOVE ADDRESS OR FAX NUMBER SHOWN ABOVE WITHIN 15 DAYS ONLY IF THIS CLAIMANT DID NOT WORK FOR YOU OR IF THE BASE PERIOD WAGES ARE INCORRECT.

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