DS9 Document EFTA01077811

Date: 05-17-2012 Virgin Islands Department of Labor ce of Unemployment Insurance Compensa Request for Separation Information Due Date: 05.26-2012 Please answer the following questions and return to the Local Office (listed below) by: 05-26-2012 This claimant applied for Unemployment Insurance Benefits on Employee's Name: MANUEL J. GONZALEZ- RODRIGUEZ Employer's Name & Address: I +f9' 1_53 , Lit 16794 ISLAND-GROUNDS;INC.4 6100 RED HOOK QUARTERS B-3 CHARLOTTE AMALIE, VI 00802 05.07-2012 and named you as their last employer: Employee's SSN: into rre c l• employer acme. S-c ci 'Lae' !Notice cx Potc,,i,al Lieu, !if y to MAY 21 2012 k LC RECEIVED NOTE: The Law provides penalties for false statements. REASON FOR SEPARATION [ ] Discharged [ ] Lack of Work / Layoff [ ] Leave of Absence [ ] Labor Dispute [ 1 Voluntary Quit Other (are there any other reasons for separation?) L.S.T, L cAi centi,ucd emP lay men'. opt re,' ions a5 or 1). Conzt.tc2. Veivin 'onl y fact- nn employment pa-..1-tan w.l-k I-ST.Ernoloy cc' ,L.LCI Submit additional facts that may affect the claimant's rights to benefits on the reverse side of this form. If this form Is returned and you have n - p F indicated facts that may affect this person's eligibility for benefits, you will be notified in writing of the Agency's decision. REPORTED SEPARATION EARNINGS Since the last day worked, has the claimant received, or will he/she receive one of the following: 1. Pension or any other retirement payment? If yes, please indicate effective date and amount: per month amount 2. Severance or any other separation earnings? If yes, please indicate type of pay and amount: [ I Severance 1 Vacation [ ] Other 3. Please indicate the following from your records: First Day Worked [ ] YES [ ]NO Effective Date: -or- $ [ j YES [ j NO lump sum pension amount lump sum severance amount lump sum vacation amount lump sum other amount Last Day Worked NOTICE OF INTERVIEW If the claimant's reason for separation is other than lack of work", the claimant will be scheduled for a Fact Finding Interview on at the local office listed below. You will be contacted it additional information is required. RETURN COMPLETED FORM TO: VI Department of Labor Division of Unemployment Insurance P.O. Box 303159 Charlotte Amalie, VI 00803.3159 Signature co n C 6 t- C nOn Printed Name I f/z Date Signed Phone Number OO12. EFTA01077811 Virgin Islands Department Of Labor Office Of Unemployment Insurance Compensation Notice Of Potential Liability Employer Id: 14497 05-17-2012 L.S.J., LLC 6100 RED HOOK QTRS, SUITE B-3 CHARLOTTE AMALIE, VI 00802 Dear Employer, This is to notify you that MANUEL J. GONZALEZ- RODRIGUEZ (Social Security Numbal). has filed a claim for unemployment benefits. According to our records, you paid this person the following wages: Year/Quarter 2011-1 2011-2 Wages Paid $10,384.62 $12,115.39 v 2011-3 $12,115.39  2011-4 $10,384.62 / Total Wages $45,000.02 / Your Account will be charged with 100 percent of the benefits, if any, because the total wages above represent that percentage of all benefit wages. If you feel you are being charged in error, please explain on the reverse side of this letter and return it to: VI Department of Labor Division of Unemployment Insurance P.O. Box 303159 Charlotte Amalie, VI 00803 -3159 Thank You for your attention in this matter, Chief Of Benefits VIDOL- UI Compensation EFTA01077812 P. I * x Communicat ion Result Report Mar.25. 2012 3:23PM ) * * I) FINANCIAL TRUST COMPANY INC. 2) Date/Time: May. 25. 2012 3:23PM Fi le No. Mode Dest inat ion Page Pg (s) Result Not Sent 2149 Memory TX 7155731 P. 2 OK Reason for error E. 1) Hans 00 or l ine fal l E. 3) No PPS., E.5) Exceeded max. E-mai l size Soloh 01.7411.11 E. 2) 84.1SY E. 4) No lassies , It connect ion 'Imp ',India...taint of Law Mao allnia•lemes1 Caw 11• 11.ou ter imam. Or. 1.••• al PO 3012 Plniniall/01116 Ma** fondles terThlial01.11x1aS 0814•06toSbtkosity It. NJ*" Mk data/ mad 1w {weeps:rya gnu.* lire10 01074.1.1. nu Wu./ ha tewk.).. Enplarars NNW WNAL J.00N/AI blillOPX'Al Ing•eyaf *all MINIM laragetraxams.a.c.eka....r1r.r.oltartm-e. S. °LIS DIM MD OCCIC OUNI1041J 04 tot..< t.1" KAY 21 21Q OWtO11FNw.C.N CODA Lll.tlt RICCEIVED 11014: 71.1.woraMa.1WIIMIYI le r loboletenallt. HIM70.4111111YPIONIION II nan.na I I ta1MWMIIn.. 11 Lamm .1 Marto 11 tyke MN. 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