Fillable PEUC Application - English

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PEUC Application - English

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Pandemic Emergency Unemployment Compensation Application FORM 359PEUC (Page 1 of 3)
APPLICATION FOR
PANDEMIC EMERGENCY UNEMPLOYMENT COMPENSATION
This is your initial application for Pandemic Emergency Unemployment Compensation (PEUC). Instructions for completing and submitting the
application can be found on our COVID-19 page (https://govstatus.egov.com/ORUnemployment_COVID19).
Please make sure you complete the entire form. Failure to complete the form will cause delays in processing your application.
Apply using the name currently on file with the Social Security Administration. Submit only one application as multiple applications will delay
processing.
APPLICANT INFORMATION
Applicant's Name (Last, First, Middle)
Social Security Number or Customer ID Number
Applicant's Mailing Address: (Street or P.O.)
Phone Number
City
State
Zip Code
Applicant Email Address
Check here if you have moved since July 1, 2019: 
PEUC FILING DATE
PEUC is available for weeks beginning March 29, 2020 through December 26, 2020.
What date do you want your PEUC claim to begin?
Week Dates
Beginning (Sunday)
Ending (Saturday)
APPLICANT EMPLOYMENT
Have you worked since you last claimed a week of benefits?
YES NO
Have you worked outside of the state of Oregon in the last 18 months?
YES NO
Have you worked for the Federal Government or Military within the last 18 months?
YES NO
If you answered “YES” to any of these questions, please complete the EMPLOYER INFORMATION section below.
If you answered “No” to all of the questions skip to the WEEKLY CERTIFICATION section.
EMPLOYER INFORMATION
EMPLOYER #1:
Employer Name
Phone Number
First Day of Work
Last Day of Work
Employer Address (Street or P.O.)
Total Gross Earnings for Above Period of Employment
City
State
Zip Code
Position
Rate of Pay
Reason you are no longer employed
Discharged/Fired/Terminated
Voluntary Quit/Resigned
Leave of absence
Temporarily Unemployed
Layoff due to permanent lack of work
Still Working/Hours Cut
Suspended
EMPLOYER #2:
Employer Name
Phone Number
First Day of Work
Last Day of Work
Employer Address: (Street or P.O.)
Total Gross Earnings for Above Period of Employment
City
State
Zip Code
Position
Rate of Pay
Pandemic Emergency Unemployment Compensation Application FORM 359PEUC (Page 2 of 3)
Reason you are no longer employed
Discharged/Fired/Terminated
Voluntary Quit/Resigned
Leave of absence
Temporarily Unemployed
Layoff due to permanent lack of work
Still Working/Hours Cut
Suspended
EMPLOYER #3:
Employer Name
Phone Number
First Day of Work
Last Day of Work
Employer Address (Street or P.O.)
Total Gross Earnings for Above Period of Employment
City
State
Zip Code
Position
Rate of Pay
Reason you are no longer employed
Discharged/Fired/Terminated
Voluntary Quit/Resigned
Leave of absence
Temporarily Unemployed
Layoff due to permanent lack of work
Still Working/Hours Cut
Suspended
WEEKLY CERTIFICATION
If you are out of work due to COVID-19, please watch our video on claiming a week of benefits here: https://youtu.be/E82E6ApKiko.
What week do you want to claim for PEUC?
Week Ending (Saturday):
___________________
Did you fail to accept an offer of work last week?
YES NO
Did you quit a job last week?
YES NO
Were you fired or suspended from a job last week?
YES NO
Were you away from your permanent residence for more than 3 days last week?
YES NO
Were you both physically and mentally able to perform the work you sought last week?
YES NO
Each day last week were you willing to work and capable of accepting and reporting for full-time, part-time and temporary
work?
You are actively seeking work if you will return to your employer or are willing to look for work when state and local
emergency declarations related to the coronavirus expire or otherwise are no longer in effect.
YES NO
Did you actively look for work last week?
If “YES” mark the temporarily unemployed box below.
YES NO
Did you work last week, or, did you receive or will you receive vacation or holiday pay for the week?
YES NO
Enter the number of hours worked (round up to the nearest hour):
___________
Enter your total gross earnings, vacation or holiday pay (before deductions), even if you have not been paid:
___________
Please Record Your Work Search Activities for Last Week:
You are required to actively seek work during each week you claim. Failure to provide your work search or failure to look for work may result in
a delay or denial of your unemployment insurance benefits.
Date
Company Name
Location
Contact Method
(in person,
phone, resume)
Type of Work Sought
Results
(hired,
not hired)
Date
Work Seeking Activities
I am a member in good standing with a union that does not allow me to seek non-union work within my trade. I have stayed in
contact with my union, and I am on the out-of-work list. I have been capable of accepting and reporting for work if dispatched
by my union. I understand false answers may result in overpaid benefits and additional penalties I must pay back.
Pandemic Emergency Unemployment Compensation Application FORM 359PEUC (Page 3 of 3)
I am temporarily unemployed because I have been laid off or had my hours reduced and expect to return to work with my
employer. I am returning to work that is full-time or work that pays more than my weekly benefit amount. There are no more
than four (4) weeks between the week I became temporarily unemployed and the week I am returning to work. I have stayed in
contact with my employer. I understand false answers may result in overpaid benefits and additional penalties I must pay back.
If you need to catch up on prior weeks, please see our COVID-19 web page for a copy of the weekly certification form.
PAYMENT INFORMATION
Payments are issued onto a US Bank Visa Reliacard or direct deposited to your account. The same method of payment will be used for future
payments that was used for prior weeks paid to you on your claim.
Do you still have your active Reliacard?
YES NO
If you were receiving direct deposit, do you wish for your payments to be deposited into your account?
YES NO
If you answered “NO” to either question, you will be issued a new Reliacard.
If you wish to sign up for electronic deposit, you can do that on our Online Claim System, or print the electronic deposit form and submit the
form with a voided check.
MISREPRESENTATION
If you misrepresent your circumstances in order to receive Pandemic Emergency Unemployment Compensation (PEUC), you will be liable to
repay the benefits that were overpaid and could face federal criminal prosecution. You will also become ineligible for any other PEUC benefits.
I agree
APPLICANT CERTIFICATION
I certify that the information I have given on this form to apply for Pandemic Emergency Unemployment Compensation is correct. 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.
Signature _________________________________________________
Date (Month, Day, Year) ______________________
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.
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PEUC Application - English

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Completed 1 July 2020

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