ET HANDBOOK NO. 384
UNEMPLOYMENT COMPENSATION FOR EX-SERVICEMEMBERS (UCX)
CHAPTER VI - FORMS AND COMPLETION
to alter the form, the redesigned form must include the
entries contained on ETA 841 except that:
(1) Items 21-22* may be omitted if such information is included on the UCX monetary determination form;
(2) If the State uses employment and wages information by weeks, hours, days, etc; in its determination of
entitlement, the State agency may modify items 21-22* as necessary; and
(3) Items 25a and 25b may be added. However, these items are for official use only and should only be
completed on the State agency copies of this form. No entries will be made on the copy given the claimant.*
State agencies may use item 25a to record the claimant’s ethnic group by entering the appropriate code number below:
- Code 1-American Indian or Alaska Native
- Code 2-Asian
- Code 3-Black or African American
- Code 4-Hispanic or Latino
- Code 5-Native Hawaiian or Other Pacific Islander
- Code 6-White
State Agencies should leave item 25b blank.*
Any other proposed modification of this form should be submitted to the appropriate ETA Regional
Office for review and approval.
VI-13
May 2003