s: Name of ClatmantANorker (if applicable). — Worker's Federal Employer Identification Number (if applicable): SSN: Job Title (only one per form): LA M b c rAP raf e Dates of Work of ClaimantANorker From 9 2-4/ 2.0 11 To 2.12_q19 ITEMS A - F BELOW ARE TO BE COMPLETED BY THE FIRM ONLY A) UC Account