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AFFIDAVITCLAIMANTS STATEMENT OF WAGES EARNEDI, SS# being duly sworn, depose and say that I worked for _ in the City or Town of in the State Of Connecticut fromto, and earned as wages the following amounts:Calendar QuarterBeginningEndingDollar AmountFirstJanuary 1, 2023March 31, 2023$SecondApril 1, 2023June 30, 2023$ThirdJuly 1, 2023September 30, 2023$FourthOctober 1, 2023December 31, 2023$Total (usually equal to form W2 issued by your employer)$Calendar QuarterBeginningEndingDollar AmountFirstJanuary 1, 2022March 31, 2022$SecondApril 1, 2022June 30, 2022$ThirdJuly 1, 2022September 30, 2022$FourthOctober 1, 2022December 31, 2022$Total (usually equal to form W2 issued by your employer)$Calendar QuarterBeginningEndingDollar AmountFirstJanuary 1, 2021March 31, 2021$SecondApril 1, 2021June 30, 2021$ThirdJuly 1, 2021September 30, 2021$FourthOctober 1, 2021December 31, 2021$Total (usually equal to form W2 issued by your employer)$My weekly gross cash wages were $__0.00 . In addition, I received $ 0.00 meals a day and $ 0.00 in tips weekly.This affidavit is made for the purpose of establishing unemployment benefit rights under Chapter 567 of the 1958 supplement to the Connecticut General Statutes, and I am aware that Section 31-273(a) provides as follows:Any person who shall knowingly make a false statement or representation or fail to disclose a material fact in order to obtain, increase, prevent or decrease any benefit, contribution or other payments under this chapter, or under any similar law of another state or of the United States in regard to which this state acted as agent pursuant to an agreement or authorized by section 31-255, whether to be made to or by himself or any other person, shall be fined not more than two hundred dollars or imprisoned not more than six months or both..Dated at this day of, 20__ Sworn to and subscribed before me.Claimants Signature Notary Public