Form UC-6Q: Quit to Care for an Ill Relative Questionnaire

Form UC-6Q: Quit to Care for an Ill Relative Questionnaire

State of Connecticut Department of Labor, Employment Securing Adjudications

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Form UC-6Q: Quit to Care for an Ill Relative Questionnaire >

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In your application for unemployment benefits, you indicated that you left your job to care for an ill relative. The following information is needed to determine your eligibility for benefits.

Please complete and submit this form online. Your form must be received within ten (10) days or a decision will be made based on available information.

"*" indicates a required field.
Information About the Individual Applying for Benefits
Your Name

First NameLast Name
Your Social Security Number
Enter the 9 digits of your Social Security Number (SSN).
Connecticut Unemployment Compensation law requires that in order to be eligible for benefits, an individual must be able to work, available for work and actively seeking work. Are you available for full time work during the day?

YesNo
If you are not available for full-time work during the day, please use the space below to describe (1) the hours when you are available and (2) what type of work you are seeking.
Enter your response in the space above.
If you are available for full-time work, please use the space below to explain how you are able to accept full-time work while providing daily care. (If you have assistance in providing care, please provide details.)
Enter your response in the space above.
Information About the Relative Receiving Care
Relative's Name

First NameLast Name
Relative's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relative's Social Security Number
Enter the 9 digits of the relative's Social Security Number (SSN).
Please use the space below to describe the nature of the relative's illness.
Enter your response in the space above.
Does this person require continuing daily care? (For example, daily care might include activities like assisting with medications and personal hygiene, preparing meals, and providing transportation to doctor appointments and/or therapy.)

YesNo
If this person requires daily care, are you providing this daily care yourself?

YesNo
If (1) this person requires daily care, and (2) you will be providing said care yourself, please use the space below to specify the type of care you provide.
Enter your response in the space above.
Was relocation required as part of the ill relative's medical treatment?

YesNo
If relocation was required as part of the ill relative's medical treatment, please use the space below to explain why the ill relative is unable to care for themselves on a daily basis.
Enter your response in the space above.
Information About Your Relationship to the Individual Receiving Care
What is your relationship to this person?

SpouseParentChildSiblingGrandparentOther
If your relationship to this person is something other than a spouse, parent, child, sibling, or grandparent, please use the space below to describe your relationship to this person.
Enter your response in the space above.
You have indicated that this person is your parent. Do you currently reside with this parent?

YesNo
If this person is your parent but you do not currently reside with them, do you plan to reside with this parent in the future?

YesNo
If (1) this person is your parent, and (2) you do not currently reside with them, and (3) you are planning to do so in the future, when do you plan to reside with this parent? Please enter the date below.
Enter your response in the space above.
Is this person a grandparent or an older sibling who raised you as a parent?

YesNo
If this person is a grandparent or older sibling who raised you as a parent, please use the space below to explain why this person cared for you instead of your mother and/or father.
Enter your response in the space above.
Was this person ever appointed your legal guardian?

YesNo
During what period of time did this person care for you? Please provide the starting and ending dates below.
Certification

You must have your relative’s doctor complete the below certification. The doctor’s certification is required before an approval of your separation can be considered. If your relative recently relocated due to his/her illness, the doctor recommending relocation must complete the certificate. Please return the certification with your response to this questionnaire as directed on the first page of this form. If no response is received, we must act on the available information.
Relative Doctor's Name

First NameLast Name
Relative Doctor's Social Security Number
Enter the 9 digits of your Social Security Number (SSN).
Relative Doctor's Signature
Date

MonthDayYear
Relative Doctor's Phone Number

Area CodePhone Number
I certify that the information I have provided above is true and correct, knowing the law provides penalties for false statements or the withholding of facts. I understand that a copy of the document may be given to any interested party upon request. If my claim for unemployment compensation benefits is approved, I understand that the decision could be reversed by a higher authority, and I agree to repay any amounts for which it is determined I am not eligible.
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Form UC-6Q: Quit to Care for an Ill Relative Questionnaire

Print a PDF Version of This Form

Information About the Individual Applying for Benefits

Information About the Relative Receiving Care

Information About Your Relationship to the Individual Receiving Care

Certification