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DEPARTMENT OF HUMAN RESOURCES AMERICAN SAMOA GOVERNMENT A.P.

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DEPARTMENT OF HUMAN RESOURCES
AMERICAN SAMOA GOVERNMENT
A.P. Lutali Executive Office Building
PAGO PAGO, AMERICAN SAMOA
Telephone: 684/ 633-4485
Fax: 684/633-5667
PANDEMIC UNEMPLOYMENT ASSISTANCE (PUA)
&
FEDERAL PANDEMIC UNEMPLOYMENT COMPENSATION (FPUC)
Initial Application
APPLICANT NAME: (Last, First, Middle)
SOCIAL SECURITY NO.#
MAILING ADDRESS (P.O. Box, Village)
GENDER: ( ) Male ( ) Female
TELEPHONE: Home: Cell:
DATE OF BIRTH:
NO.# OF DEPENDENTS:
MARITAL ( ) Single ( ) Married ( ) Widowed
STATUS: ( ) Separated ( ) Divorced
CONTACT PERSON: _________________________________________________________________________________
RELATIONSHIP :
___________________________________________________________________________________
CONTACT NO.#:_____________________________________________CELL:__________________________________
Check all sources of income or livelihood at the time that you stopped or reduced your work due to COVID-19 public
emergency .
( ) Employment ( ) PENSION/RETIREMENT ANNUITY
( ) SELF-EMPLOYMENT: ( ) FARMER ( ) FISHERMAN
If box for “Pension” checked, provide amount of pension: $__ ____ Date pension began:____________ If pension is from a prior
employer, provide employer name:___________________________________.
NOTE: If you were self-employed, engaged in farming or fishing activities, you must also complete a Supplemental Questionnaire(s) such as the
Questionnaire for Self-employed Individuals - Farmers or the Questionnaire for Self-employed Individuals - Fishermen.
B. APPLICANT EMPLOYMENT AND INFORMATION
PUA/FPUC APPLICATION -2
A. APPLICANT REQUEST
I hereby apply for PANDEMIC UNEMPLOYMENT ASSISTANCE (PUA) for the period of unemployment resulting from the COVID-19 Pandemic. I
attest that my unemployment, partial unemployment, inability or unavailability to work was a result of the disaster as follows (explain in detail how
your unemployment/self-unemployment (total or partial) was a result of the COVID-19 public emergency and include last day worked:
___________________
(Initial Box) By completing this section, I CERTIFY that all of the information regarding my loss of employment, self-employment, or inability,
unavailability to work is due to COVID-19, that my statements are true and correct to the best of my knowledge, and I am aware that any
misinformation I provide is subject to legal penalties and may result in prosecution under the law.
COMMENTS:___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
PUA APPLICATION 1-7
WORK RECORD. List all employment, full-time and part-time, for the most recently completed tax year and through the current
period beginning with your most recent employment and/or self-employment. Include Federal, civilian, military, and any out-
of-state employment. Include an attachment if you need to list additional employment.
EMPLOYER NAME: ____________________________________________
ADDRESS: P.O. BOX: _____________________Village:_______________
Employer Telephone:___________________________________________
PLACE EMPLOYED: ___________________________________________
Rate of Pay/salary/or self-employed income _______________________
Hours Per Week__________ Employed: ( ) Full-time ( ) Part time
From _________________________ To ______________________________
Type of work:_____________________________________________________
Reason for Separation:
( ) Separated due to the COVID-19 public health emergency
( ) Laid off – Lack of work ( ) Quit ( ) Discharged
( ) Still employed ( ) Other Explain: ___________________________
EMPLOYER NAME: ____________________________________________
ADDRESS: P.O. BOX: _____________________Village:_______________
Employer Telephone:___________________________________________
PLACE EMPLOYED: ___________________________________________
Rate of Pay/salary/or self-employed income _______________________
Hours Per Week__________ Employed: ( ) Full-time ( ) Part time
From _________________________ To ______________________________
Type of work:_____________________________________________________
Reason for Separation:
( ) Separated due to the COVID-19 public health emergency
( ) Laid off – Lack of work ( ) Quit ( ) Discharged
( ) Still employed ( ) Other Explain: ___________________________
EMPLOYER NAME: ____________________________________________
ADDRESS: P.O. BOX: _____________________Village:_______________
Employer Telephone:___________________________________________
PLACE EMPLOYED: ___________________________________________
Rate of Pay/salary/or self-employed income _______________________
Hours Per Week__________ Employed: ( ) Full-time ( ) Part time
From _________________________ To ___________________________
Type of work:__________________________________________________
Reason for Separation:
( ) Separated due to the COVID-19 public health emergency
( ) Laid off – Lack of work ( ) Quit ( ) Discharged
( ) Still employed ( ) Other Explain: ___________________________
PUA/FPUC APPLICATION -2-7
Check all sources of income or livelihood at the time that you stopped or reduced your work due to COVID-19 Public Emergency.
( ) Employment ( ) Pension/Retirement Annuity ( ) Self-Employment ( ) Farmer ( ) Fisherman
If the box for *Pension* checked, provide amount of pension:$________________ Date pension began:___________________________________
If pension is from a prior employer, provide employer name, including U.S. Military:____________________________________________________
1. Are you required to make or do you owe child support payments under a court order?
YES
NO
If Yes, where (State/Territory)?
2. Were you a director, officer, owner, or shareholder of a business or corporation within
the past 15 months?
If Yes, Name of Business:
3. Was your place of employment closed?
a. If yes, reason for closure
4. Were you unable to reach your place of employment?
If yes, explain:
5. Were you diagnosed with COVID-19 or experiencing symptoms and seeking diagnosis?
a. If Yes, what date did you first experience symptoms :
b. If Yes, what period of you have been unable to work because of COVID-19
diagnosis or symptoms:
6. Were you scheduled to start a new job or business but were unable to as a result of the
COVID-19 public health emergency?
a. If Yes, what is the name of company you were to begin work with or business
you were to start:
b. Location and phone number of company or business
c. Date you were scheduled to start work
7. Are you attending or planning to attend school or training?
a. If Yes, please state the name of the school:
b. Days & hours attending
8. Do you certify under penalty of perjury that you are a citizen of the U.S?
a. If No, are you in a satisfactory immigration status?
b. Alien Reg. No (located on permanent resident green card).
c. Place of Birth
9. Do you wish to have Federal taxes withheld from your PUA benefits?
PUA/FPUC APPLICATION -3-7
10
.
Please check which of the following categories applies to you (Please be aware intentionally
misrepresentation of this information is fraud). You also need to provide specific details in the box
below:
YES
a. You have been diagnosed with COVID-19 or is experiencing symptoms of
COVID-19 and are seeking a medical diagnosis .
b. A member of your household has been diagnosed with COVID-19.
c. You are providing care for a family member or a member of your household,
who has been diagnosed with COVID-19.
d. A child or other person in the household for which your are the primary
caregiving responsibility is unable to attend school or another facility that is
closed as a because of the COVID-19 public health emergency and such
school or facility care is required for you to work.
e. You are unable to reach the place of employment because of a quarantine
imposed as a direct result of the COVID-19 public health emergency.
f. You are unable to reach the place of employment because you have been
advised by a health care provider to self-quarantine due to concerns related
to COVID-19.
g. You were scheduled to commence employment and do not have a job or are
unable to reach the job as a direct result of the COVID-19 public health
emergency
h. You have become the breadwinner or major support for a household
because the head of the household has died as a direct result of COVID-19.
i. You quit your job as a direct result of COVID-19.
j. Your place of employment is closed as a direct result of the COVID-19 public
health emergency.
k. You are an independent contractor who is unemployed, (total or partial) or is
unable or unavailable to work because the COVID-19 public health
emergency has severely limited your ability to continue performing your
customary job.
l. Employees whose hours are reduced as a direct result of Covid-19.
COMMENTS:________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
PUA/FPUC APPLICATION -4-7
C. FILING FOR PAST WEEKS
List below all weeks after : the COVID-19 public emergency first affected you, you were unemployed
(total or partial) due to the COVID-19 public health emergency, and for which you are claiming PUA.
Report gross earnings from employment and net earnings from self-employment
.
WEEK ENDING
HOURS WORKED
EARNINGS
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
PUA/FPUC APPLICATION -5-7
1. For the weeks claimed above, answer the following questions by checking the appropriate
box(es).
a. Did you apply for, receive, or believe may
be eligible for any of the following?
YES NO
AMOUNT
PERIOD
From
COVERED To
(1)
Unemployment Compensation under
any State or Federal
Law?
(2)
Any amounts for loss of wages due to
illness or disability?
(3)
Any type of private income protection
insurance?
(4)
Any amount as a Supplemental
Unemployment benefit
(SUB)?
b. Were any amounts payable to you from
any retirement, pension or annuity under a
public or private plan or system?
YES NO
c. Were you able and available for work during each of the
weeks claimed above, except that you are unemployed (total
or partial) due to the COVID-19 public health emergency?
d. Did you accept all work offered during each of the weeks
claimed above
e. Were you self-employed full-time prior to the onset of the
COVID-19 public health emergency?
f. Were you employed part-time prior to the onset of the
COVID-19 public health emergency?
g. How many hours per week were you employed part time
during the week?
h. If you work full-time, how many hours per week were you
working prior to your separation due to the COVID-19 public
health emergency?
PUA benefits may be subject to federal income tax. You may receive a 1099 form for the prior
calendar year showing the amount of PUA benefit you received and are responsible to report
these benefits, if you are required to file federal income tax.
PUA/FPUC APPLICATION 6-7
D. APPLICANT CERTIFICATION
I CERTIFY that all of the information I have given on this application and forms related to this
application is correct to the best of my knowledge and belief, and that I have supplied this information
in order to obtain PANDEMIC UNEMPLOYMENT ASSISTANCE (PUA). The information that I am
providing true and correct to the best of my knowledge. I understand that I am providing this
information under the penalty of perjury.
I understand that Federal funds are provided and that under 18 U.S.C. 1001, I may be subject to
prosecution for willfully concealing material facts or knowingly making a false statement to obtain
PUA to which I am not entitled. I am furnishing my Social Security Number as required under 26
U.S.C.6109(d) for purpose of reporting PUA as a Federal taxable income and for determining my
entitlement to PUA. I understand that information regarding my claim may be furnished to requesting
agencies defined in the Deficit Reduction Act (DEFRA) (PL 98-369) for purpose of income and
eligibility verification.
SIGNATURE OF APPLICANT:
SIGNATURE OF INTERVIEWER:
DATE (Month/ Day/Year)
PUA/FPUC APPLICATION -7-7
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DEPARTMENT OF HUMAN RESOURCES AMERICAN SAMOA GOVERNMENT A.P.

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Completed 25 April 2021

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