DS9 Document EFTA01077824

Date: 05-30-2012 Virgin Islands Department of Labor Office of Unemployment Insurance Compensation Request for Separation Information Due Date: 06-08-2012 Please answer the following questions and return to the Local Office (listed below) by: 06-08-2012 This claimant applied for Unemployment Insurance Benefits on 05-24.2012 and named you as their last employer: Employee's Name: MELVIN E. OCASIO FLORES Employee's SSN: Employer's Name & Address: 16734 ISLAND GROUNDS , INC. 6100 RED HOOK QUARTERS B-3 CHARLOTTE AMALIE, VI 00802 RECEIVED JUN 01 2012 NOTE: The Law provides penalties for false statements. REASON FOR SEPARATION [ ] Discharged [ J Lack of Work! Layoff ( ] Leave of Absence ) Labor Dispute [ j Voluntary Quit [ J Other (are there any other reasons for separation?) 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 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: [ j YES Effective Date: [ ] NO per month amount -or- $ 2. Severance or any other separation earnings? [ J YES [ NO If yes, please indicate type of pay and amount: [ J Severance lump sum severance amount [ j Vacation lump sum vacation amount [ ] Other lump sum other amount 3. Please indicate the following from your records: First Day Worked Last Day Worked NOTICE OF INTERVIEW lump sum pension amount 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 if additional information is required. RETURN COMPLETED FORM TO: VI Department of Labor Division of Unemployment Insurance Box 303159 Charlotte Amalie, VI 00803.3159 Signature Printed Name Date Signed Phone Number EFTA01077824 Virgin Islands Department Of Labor Office Of Unemployment Insurance Compensation Notice Of Potential Liability Employer Id: 16734 05-30-2012 ISLAND GROUNDS , INC. 6100 RED HOOK QUARTERS B-3 CHARLOTTE AMALIE, VI 00802 Dear Employer, This is to notify you that MELVIN E. OCASIO FLORES (Social Security Number: , has filed a claim for unemployment benefits. According to our records, you paid this person t e o owing wages: Year/Quarter Wages Paid 2011-1 $12,275.00 2011-2 $12,995.00 2011-3 $12,150.00 2011-4 $12,500.00 Total Wages $49,920.00 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 Box 303159 Charlotte Amalie, VI 00803 -3159 (340) 776-3700 Thank You for your attention in this matter, Chief Of Benefits VIDOL- UI Compensation EFTA01077825