Official Nebraska Department of Labor

Request for Extension to Worker Attachment- Unemployment Insurance

THIS FORM SHOULD ONLY BE USED TO EXTEND THE RETURN-TO-WORK DATE OF AN EXISTING ATTACHMENT PERIOD.

Extension of an existing attachment may be granted for up to two weeks upon proof of short-term circumstances beyond the employer’s control that prevent the worker from returning to work.

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

Back to List