Official Nebraska Department of Labor

Request for Extension to Worker Attachment

Due to abnormal circumstances, a two-week extension of attachment beyond the initial 16 week period may be granted.

This form should NOT be completed by employees.

Company Name *

Employer Account Number *

Company Email *

Reason for Request *

Is this the company’s first request for an extension to worker attachment status? *

Yes

Have the workers listed returned to work since the original period of layoff? *

Yes

Please list all employees on one form. Include the original return date for each employee listed.

Employee Name*	Last 4 Digits of SSN*	Last Day Worked*	New Return Date*

+ Add Employee

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