PandemicUnemploymentAssistanceApplication 877 FormUIPUB81PUA(Page1of6)
INITIALAPPLICATIONFOR
PANDEMICUNEMPLOYMENTASSISTANCE
A. APPLICANTINFORMATION
Applicant'sName(Last,First,Middle) SocialSecurityNumber DateofBirth(Mo.,Day,Yr.)
Applicant'sMailingAddress:(StreetorP.O.) PhoneNumber Sex(Checkone)
Male Female
City State ZipCode AreyouofHispanicorLatinoethnicity?
Yes No
ApplicantEmailAddress Race:(Checkallthatapply)
AmericanIndianorAlaskaNativeAsian
HawaiianNativeorOtherPacificIslander White
BlackorAfricanAmerican Other
PreferredMethodofContact
PhoneEmail
WeverifyallsocialsecuritynumbersthroughacomputermatchwiththeSocialSecurityAdministration.Yourunemploymentinsurance
applicationcannotbecompletedifthismatchisnotsuccessful.
TheInternalRevenueCodeandOregonAdministrativeRulesrequirethatyoudiscloseyourSocialSecurityNumberwhenclaiming
unemploymentcompensation.YourSocialSecurityNumberwillbeusedtoreportyourunemploymentbenefitstotheInternalRevenueService
andOregonDepartmentofRevenueasincomethatistaxable.ThenumberwillbesenttotheSocialSecurityAdministrationforidentity
verification.ThenumbermaybeusedforstateagencydebtcollectionactivitiesandmaybesenttoU.S.BanktoissueyouaReliaCardVISAcard
throughwhichyouwillbepaidbenefits.
B. APPLICANTEMPLOYMENT
Inordertocompletetheamountofmyweeklyentitlementtopandemicunemploymentassistance,ICERTIFYthatIhadthefollowing
employmentand/orself‐employmentduringthelast18months.
NameofEmployer
(orSelfEmployment)
EmployerAddress PhoneNumber
PeriodEmployed
From To
C. ELIGIBILITYQUESTIONS
WereyouscheduledtostartanewjobthathassinceclosedasadirectresultoftheCOVID‐19publichealth
emergency?
YESNO
If“YES”,pleaseenterthedateyouwereexpectedtostartwork,thedateyournewjobclosed,andthenameof
thebusiness.
Didyouapplyfor,receive,orwouldyoubeeligibletoreceiveifyouhadeverappliedfor:
(1)UnemploymentcompensationunderanyStateorFederallaw? YESNO
(2)Anyamountsforlossofwagesduetoillnessordisability? YESNO
(3)Anytypeofprivateincomeprotectioninsurance? YESNO
(4)Anyamountasasupplementalunemploymentbenefit(SUB)? YESNO
PandemicUnemploymentAssistanceApplication 877 FormUIPUB81PUA(Page2of6)
Areyoureceivingorwillyoureceiveretirementpay(otherthanSocialSecurity)withinthenext12months? YESNO
If“YES”,pleaseprovidethenameoftheemployerthatmaintainedorcontributedtothisretirementplan?
HaveyoubeendiagnosedwithCOVID–19,orareyouexperiencingsymptomsofCOVID–19andseekingamedical
diagnosis?
YESNO
If“YES”,pleaseenterthedateyouwerediagnosedorwhenyoubeganexperiencingsymptoms
HasamemberofyourhouseholdbeendiagnosedwithCOVID–19? YESNO
If“YES”, pleaseenterthedatethehouseholdmemberwasdiagnosed.
AreyoucaringforafamilymemberoramemberofyourhouseholdwhohasbeendiagnosedwithCOVID–19? YESNO
If“YES”,pleaseenterthedatethehouseholdmemberwasdiagnosed.
Isthereachildorotherpersoninthehousehold,forwhomyouhavetheprimarycaregivingresponsibilityfor,that
isunabletoattendschooloranotherfacilitythatclosedasadirectresultoftheCOVID‐19publichealthemergency
andsuchschoolorfacilitycareisrequiredforyoutowork?
YESNO
If“YES”,pleaseenterthenameofthefacilitythatclosedandthedateoftheclosure.
Haveyoubecomethebreadwinnerorproviderofmajorsupportforahouseholdbecausetheheadofthe
householdhasdiedasadirectresultofCOVID–19?
YESNO
If“YES”,pleaseenterthedateyoubecametheproviderforahousehold.
HasyourplaceofemploymentclosedasadirectresultoftheCOVID–19publichealthemergency? YESNO
If“YES”,pleaseenterthedateyourplaceofemploymentclosedandthenameofthebusiness.
HaveyouquitajobasadirectresultofCOVID–19? YESNO
If“YES”,pleaseenterthedateyouquit,thenameofthebusiness,andthereasonyouvoluntarilyleftwork.
Areyouunabletoreachyourplaceofemploymentbecauseyouhavebeenadvisedbyahealthcareproviderto
self‐quarantineduetoconcernsrelatedtoCOVID–19?
YESNO
If“YES”,pleaseenterthereasonwhyyouareunabletoreachyourplaceofemploymentandthedatethis
began.
PandemicUnemploymentAssistanceApplication 877 FormUIPUB81PUA(Page3of6)
Areyouunabletoreachyourplaceofemploymentbecauseofaquarantineimposedasadirectresultofthe
COVID‐19publichealthemergency?
YESNO
If“YES”,pleaseenterthereasonwhyyouareunabletoreachyourplaceofemploymentandthedatethis
began.
Doyouhavetheabilitytocontinuetoreceivepaymentfromyouremployerwhileworkingfromhome? YESNO
If“YES”,pleaseenterthereasonwhyyouhaverefusedtoacceptateleworkingoptionfromyouremployer.
Areyoureceivingpaidsickleaveorotherpaidleavebenefits? YESNO
If“YES”,pleaseenterthedateyoubegantoreceivepaidsickleaveorpaidleavebenefitsandwhoyouare
receivingthispaymentfrom,ifyouknowanenddatepleaseincludethat.
Areyoucurrentlyself‐employed? YESNO
If“YES”,youMUSTanswerthequestionsinsectionD.
D. SELF‐EMPLOYMENTINFORMATION
Atthetimeofthepandemic,wasthisself‐employmentyourprimaryoccupationandprimarymeansoflivelihood? YESNO
If"NO",explain.
Whatservicesdidyouperform?
Doyouhaveabusinessname? YESNO
If“YES”,whatisyourbusinessname?
Doyoufileabusinessreturn?(Ex:ScheduleC,1120ora1065) YESNO
If“YES”,pleaselistwhatreturnsyoufile.
Doyoudeterminehowtheworkistobeperformed? YESNO
Doyouhavetherighttohiresomeonetohelpyouperformyourservices? YESNO
If“YES”,canyoudischargethem?
YESNO
Doyoudeterminewheretheworkisgoingtobeperformed? YESNO
Doyoudetermineyourrateofcompensation? YESNO
Doyouhaveaninvestmentintools,equipment,etc.? YESNO
If“YES”,howmuch?
PandemicUnemploymentAssistanceApplication 877 FormUIPUB81PUA(Page4of6)
Canthecompanyyouprovideservicestoterminateyou? YESNO
Doyouhavemorethanoneclient? YESNO
If“YES”,howmanyclientsdoyouhave?
E. AUTHORIZATIONFORTAXWITHHOLDING
Anyunemploymentinsurancebenefitsyoureceivearefullytaxableincomeifyouarerequiredtofileataxreturn.Youmayneedtomake
estimatedtaxpayments.Formoreinformationonestimatedtaxpayments,contacttheInternalRevenueService.Forstatetaxinformation,
contacttheOregonDepartmentofRevenue.
Youmaychoosetohave10%ofyourbenefitswithheldforfederaltaxesand/or6%forstatetaxes.
Doyouchoosetohave10%ofyourunemploymentbenefitswithheldforfederalincometaxes? YES NO
Doyouchoosetohave6%ofyourunemploymentbenefitswithheldforstateincometaxes? YES NO
ThisauthorizationwillremainineffectforthisclaimuntiltheOregonEmploymentDepartmenthasreceivedwrittennotificationfromyouofits
termination.
F. RETROACTIVEFILING
Listbelowallweeksfollowingthedateofthepandemicthatyouweretotallyorpartiallyunemployedduetothepandemicandforwhichyou
areclaimingPUA.Reportgrossearningsfromemploymentandgrossearningsfromself‐employment.
WeekEnding
Hours
Worked
Gross
Earnings TypeofEarnings WeekEnding
Hours
Worked
Gross
Earnings TypeofEarnings
1.  4. 
2. 5.
3. 6.
Fortheweeksclaimedabove,answerthefollowingquestionsbycheckingtheappropriatebox(es). Completetheinformationrequestedinthe
paymentboxbelowifyouanswer“Yes”toanyquestionsinitem1below.
1. Didyouapplyfororreceive:
a. Anyinsurancepaymentsforlossofwagesduetoillnessordisability? YESNO
b. Anypaymentsfromprivateincomeprotectioninsurance? YESNO
c. Anypaymentsofasupplementalunemploymentbenefit? YESNO
d. Wereanyamountspayabletoyoufromanyretirement,pension,orannuitypaymentsfromaplan
contributedormaintainedbyanemployeryoureceivedpaymentfromin2019?
YESNO
Typeofeach
PaymentAmount
PeriodCovered
From To




2. Wereyouableandavailableforworkduringthisweekbasedonourstaterequirements? YESNO
3. AreyoucurrentlyimpactedbytheCOVID‐19publichealthemergency? YESNO
i. If“YES”,explain.
4. Didyourefuseanyworkduringanyoftheweeksclaimedabove? YESNO
- select one -
- select one -
- select one -
- select one -
- select one -
- select one -
PandemicUnemploymentAssistanceApplication 877 FormUIPUB81PUA(Page5of6)
G. RELIACARDDISCLOSURE
U.S.BankReliaCard®Pre‐AcquisitionDisclosure
ProgramName:OregonUnemploymentInsurance
ReferenceDate:June2017
Youhaveoptionsastohowyoureceiveyourpayments,includingdirectdeposittoyourbankaccountorthisprepaidcard.
Askyouragencyforavailableoptionsandselectyouroption.
Monthlyfee
$0
Perpurchase
$0
ATMwithdrawal
$0in‐network
$2.00*out‐of‐network
Cashreload
N/A
ATMBalanceInquiry(in‐networkorout‐of‐network) $0
CustomerService(automatedorliveagent) $0percall
Inactivity(after365dayswithnotransactions) $2.00permonth
Wecharge3othertypesoffees.
*Thisfeecanbelowerdependingonhowandwherethiscardisused.
SeetheaccompanyingFeeScheduleforfreewaystoaccessyourfundsandbalanceinformation.
Nooverdraft/creditfeature.
YourfundsareeligibleforFDICinsurance.
Forgeneralinformationaboutprepaidaccounts,visitcfpb.gov/prepaid.
Finddetailsandconditionsforallfeesandservicesinsidethecardpackageorcall1‐855‐279‐1270orvisitusbankreliacard.com.
U.S.BankReliaCard®FeeSchedule
ProgramName:OregonUnemploymentInsurance
EffectiveDate:May2018
Allfees Amount Details
Getcash
ATMWithdrawal(in‐network) $0 Thisisourfeeperwithdrawal.“In‐network”referstotheU.S.BankorMoneyPass®ATM
networks.Locationscanbefoundatusbank.com/locationsormoneypass.com/atm‐locator.
ATMWithdrawal(out‐of‐network) $2.00 Thisisourfeeperwithdrawal.Thisfeeiswaivedforyourfirst2ATMwithdrawalsper
month,whichincludesbothATMWithdrawals(out‐of‐network)andInternationalATM
Withdrawals.“Out‐of‐network”referstoalltheATMsoutsideoftheU.S.Bankor
MoneyPassATMnetworks.YoumayalsobechargedafeebytheATMoperatorevenifyou
donotcompleteatransaction.
TellerCashWithdrawal $0 Thisisourfeeforwhenyouwithdrawalcashoffyourcardfromatelleratabankorcredit
unionthataccepts(Visa®.
Information
ATMBalanceInquiry(in‐network) $0 Thisisourfeeperinquiry.“In‐network”referstotheU.S.BankorMoneyPass®ATM
networks.Locationscanbefoundatusbank.com/locationsormoneypass.com/atm‐locator.
ATMBalanceInquiry(out‐of‐network) $0 Thisisourfeeperinquiry.“Out‐of‐network”referstoalltheATMsoutsideoftheU.S.Bank
orMoneyPassATMnetworks.YoumayalsobechargedafeebytheATMoperator.
UsingyourcardoutsidetheU.S.
InternationalTransaction 3% Thisisourfeewhichapplieswhenyouuseyourcardforpurchasesatforeignmerchants
andforcashwithdrawalsfromforeignATMsandisapercentageofthetransactiondollar
amount,afteranycurrencyconversion.SomemerchantandATMtransactions,evenifyou
and/orthemerchantorATMarelocatedintheUnitedStates,areconsideredforeign
transactionsundertheapplicablenetworkrules,andwedonotcontrolhowthese
merchants,ATMsandtransactionsareclassifiedforthispurpose.
PandemicUnemploymentAssistanceApplication 877 FormUIPUB81PUA(Page6of6)
InternationalATMWithdrawal $2.00 Thisisourfeeperwithdrawal.Thisfeeiswaivedforyourfirst2ATMwithdrawalsper
month,whichincludesbothATMWithdrawals(out‐of‐network)andInternationalATM
Withdrawals.YoumayalsobechargedafeebytheATMoperatorevenifyoudonot
completeatransaction.
Other
CardReplacement $0 Thisisourfeepercardreplacementmailedtoyouwithstandarddelivery(upto10
businessdays).
CardReplacementExpeditedDelivery $15.00 Thisisourfeeforexpediteddelivery(upto3businessdays)chargedinadditiontoanyCard
Replacementfee.
Inactivity $2.00 Thisisourfeechargedeachmonthafteryouhavenotcompletedatransactionusingyour
cardfor365consecutivedays.
YourfundsareeligibleforFDICInsurance.YourfundswillbeheldatU.S.BankNationalAssociation,anFDIC‐insuredinstitution,andareinsured
upto$250,000bytheFDICintheeventU.S.Bankfails.Seefdic.gov/deposit/deposits/prepaid.htmlfordetails.
Nooverdraft/creditfeature.
ContactCardholderServicesbycalling1‐855‐279‐1270,bymailatP.O.Box551617,Jacksonville,FL32255orvisitusbankreliacard.com.
Forgeneralinformationaboutprepaidaccounts,visitcfpb.gov/prepaid.Ifyouhaveacomplaintaboutaprepaidaccount,calltheConsumer
FinancialProtectionBureauat1‐855‐411‐2372orvisitcfpb.gov/complaint.
IhavereadtheReliaCardInformation
H. MISREPRESENTATION
Iunderstandthatmakingthecertificationisunderpenaltyofperjuryandthatintentionalmisrepresentationinordertoobtainpaymentsto
whichIamnotentitledtoreceivemaybesubjecttocriminalprosecution.
Iagree
I. APPLICANTCERTIFICATION
IcertifythattheinformationIhavegivenonthisformiscorrect,andthatIhavesuppliedtheinformationvoluntarily,inordertoobtain
PandemicUnemploymentAssistance.IknowthatFederalfundsareprovidedandthatpenaltiesareprescribedbylawforwillful
misrepresentationorconcealmentofmaterialfactsinordertoobtainassistancepaymentstowhichIamnotentitledtoreceiveundertheACT.
TheinformationgatheredbytheEmploymentDepartmentmaybeusedbyotherstateandfederalagenciesforverificationofeligibilityfor
otherprograms.Therefore,IAUTHORIZEtheEmploymentDepartmenttoreleaseTOANYSOURCEtheinformationforpurposesauthorized
underEmploymentDepartmentlaw.Furthermore,Iattestunderpenaltyofperjurythat:
IamacitizenornationaloftheUnitedStates YES NO
IfNO,areyouinsatisfactoryimmigrationstatus? YES NOAlienReg#____________________
Signature_________________________________________________ Date(Month,Day,Year)______________________
IfyouarefoundtobeeligibleforPUAwewillestablishaminimumclaimof$205.Ifyouwishtohaveusevaluateyourclaimforanincreased
weeklybenefitamount,youmustprovideproofofincomefortaxyear2019.Inordertohavethepossibilityofahigherclaimamountyoumust
haveearningsinexcessof$16,480fortheyear2019.Youcanutilizetheform196PUAtoidentifyhowmuchyoumaybeeligibletoreceive.
Pleasesubmityourcompletedapplicationto:
OregonEmployment
Department
POB
ox14165
Salem,Oregon97311
Fax:(503)371‐2893 Questions:OED_PUA_INFO@oregon.gov
Disclaimer:Informationyousendviaemailmaynotbesecure.
TheOregonEmploymentDepartmentisanequalopportunityprogram/employer.Thefollowingservicesareavailablefreeofcostuponrequest:Auxiliaryaidsor
servicesandalternateformatstoindividualswithdisabilitiesandlanguageassistancetoindividualswithlimitedEnglishproficiency.Askoneofourstaffformore
information.
ElDepartmentodeEmpleodeOregonesunprograma/empleadorquerespetalaigualdaddeoportunidades.Disponemosdelossiguientesserviciosapedidoysin
costo:Serviciosoayudasauxiliares,yformatosalternosparapersonascondiscapacidadesyasistenciadeidiomasparapersonasconconocimientolimitadodel
inglés.Paramayorinformación,pregunteanuestropersonal.