IM-39 Instructions

REQUEST FOR EMPLOYMENT SECURITY INFORMATION - OUTSIDE STATE OF MISSOURI

PURPOSE:   To provide the county, region, or state office with information regarding wages reported and/or Unemployment Compensation (UC) from claimant’s earnings outside the State of Missouri.

Use this form at application or reinvestigation or when information is received indicating that an individual works or receive unemployment insurance from another state. This inquiry will be appropriate if the claimant or an assistance group/household member:

• reports wages or unemployment insurance in another state;
• has a history of employment in another state;
• recently moved to Missouri from another state and there is reason to believe s/he may be employed or receiving unemployment insurance in that state (for example, issues of unexplained management); or
• lives in close proximity to another state and there is reason to believe s/he may be employed or receiving unemployment insurance in that state.

FORM AVAILABILITY:   The IM-39 is available as an electronic form only.

MANUAL REFERENCES: BCCT/MA:  1300.000.00 - 1325.000.00
OAA/PTD:  1000.000.00 - 1060.010.00
MAF/MC+:  0905.000.00 - 0955.020.00
MA:  0800.000.00 - 0870.045.00
SNC:  0600.000.00 - 0635.005.00
SAB/BP:  0400.000.00 - 0440.000.00
TA:  0200.000.00 - 0300.015.00

NUMBER OF COPIES AND DISPOSITION:   Complete an original and one copy. Place the copy in the case record. Destroy the copy upon receipt of the completed original.

For all states except Kansas, send the original to the Employment Security agency in the state where the claimant lived and/or worked.

To inquire about wages or unemployment insurance from Kansas, send the original to:

Patricia A. Hammett
Kansas City State Office Building
615 East 13th Street
Kansas City, MO 64106

The request may be sent to Patricia Hammett via e-mail by following the steps listed below:

• obtain the form from the IM Forms Manual on the Intranet;
• complete the form and save it as a Word document; and
• e-mail the form as an attachment to: Patricia.A.Hammett@dss.mo.gov.

INSTRUCTIONS FOR COMPLETION:

FROM

COUNTY OFFICE NAME: Enter the name of the requesting county office.

TELEPHONE NO: Enter the office telephone number, including the area code.

DATE: The date is system generated when the letter is created.

ADDRESS (STREET): Enter the county office street address.

CITY, STATE, ZIP CODE: Enter the city, state, and zip code of the county office address.

TO

STATE AGENCY NAME: Enter the name of the Employment Security agency where the request is being sent.

NOTE: Agency names and addresses may be obtained from the Public Human Services Directory available in each county office, or through the receiving state’s web site.

RE

CASE NAME: Enter the name of the claimant.

SOCIAL SECURITY NUMBER: Enter the claimant’s Social Security Number.

CASE DCN: Enter the claimant’s Departmental Client Number (DCN).

NAME (IF DIFFERENT FROM CASE NAME): Enter the name of the individual for whom the information is requested if it is not the claimant listed in Case Name.

SOCIAL SECURITY NUMBER: Enter the Social Security number of the individual for whom the information is requested if it is not the claimant listed in Case Name.

THE ABOVE-NAMED INDIVIDUAL--: Check the appropriate box in this section that fits the case situation. If “Other” is selected, state the reason the inquiry about employment or unemployment insurance is being made.

The following sections are completed by the receiving agency:

• Has the individual been employed in your state?;
• Name of employer;
• Employer’s address;
• Employer’s telephone number;
• Dates of employment;
• Is the individual currently receiving unemployment insurance in your state?;
• Current benefit amount;
• Account balance; and
• Last Check Date.

COMMENTS: Enter any special requests that need further clarification, or any additional information that may be useful.

Example: “Ms. A states she was employed at ABC Industries until last May, when she was laid off.”

HOUSEHOLD MEMBER SIGNATURE/DATE: The individual for whom information is needed signs and dates the form.

ELIGIBILITY SPECIALIST: Enter the name of the Eligibility Specialist who is requesting the information.

PHONE NUMBER: Enter the office telephone number of the Eligibility Specialist who is requesting the information.

CASELOAD NO: Enter the caseload number of the Eligibility Specialist who is requesting the information.

NOTE: Some states' workforce agencies may assess a fee for providing information. If a state responds to the request by stating that there is a charge for the information, file the response in the case record to document the reason that the information is not available.