Employer Affidavit for Filing Electronic Partials

This form is to be executed by employer for filing electronic partials.




649 Monroe Street
Montgomery, Alabama 36131
Week Ending Date _________________ UI Account Number ________________________
I certify under penalty of law that the individuals being submitted for unemployment benefits for this
(1) are full time employees
(2) are laid off temporarily for lack of work only
(3) worked all available hours during the week
(4) are not receiving a retirement pension
(5) are not in school
(6) do not have an active interstate claim
(7) are not receiving Worker’s Compensation payments
(8) have been advised to report all pay received from odd-jobs or any other source and that this pay
has been recorded in the appropriate field
(9) have been advised they must be able and available for work each day claimed.
I certify that the data submitted is complete and accurate information and authorize the Department
to file unemployment claims for each individual included in the electronic file. I certify these
employees have authorized this employer to file these claims on their behalf and to provide wage
information to the Department. I certify that these employees have been allowed to choose their
preferred federal tax deduction option. I further certify that these employees have been advised that
they must provide me with their current address and if it changes they must notify me immediately.
I understand that my employees’ AL Vantage Debit Cards cannot be mailed to the employer’s
I understand that the law provides penalties for submitting false claims. I further understand that
under the Rules of the Department, any employer found to be abusing the purpose and intent of the
Partial Claims Program will be prohibited from using the system.
Questions concerning this document should be referred to Payment Processing Unit at
Signature _________________________________________________ Title _________________________
Employer Name ___________________________________________________________________________
Address ____________________________ ___________________________________________
Telephone: Date: