Fill - Free fillable PUA Application

PandemicUnemploymentAssistanceApplication 877 FormUIPUB81PUA(Page1of5)

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INITIALAPPLICATIONFOR

PANDEMICUNEMPLOYMENTASSISTANCE

ThisisyourinitialapplicationforPandemicUnemploymentAssistance(PUA).Instructionsforcompletingandsubmittingtheapplicationcanbefoundonour

CARESActpage(https://govstatus.egov.com/ui‐benefits/CARES).

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.

Duetofederalreportingrequirementsandsystemlimitations,onlyMaleandFemaleoptionsarecurrentlyavailable.However,therewillbenodelayinprocessing

yourclaimifthegenderelectiondoesnotmatchwhatisonfilewiththeSocialSecurityAdministration.

A. APPLICANTINFORMATION

Applicant'sName(Last,First,Middle)(PleaseusenameonfilewiththeSocialSecurityAdministration) DateofBirth(Mo.,Day,Yr.)

Applicant'sMailingAddress:(StreetorP.O.) SocialSecurityNumber Sex(Checkone)

MaleFemale

City State ZipCode AreyouofHispanicorLatinoethnicity?



Yes No

ApplicantEmailAddress PhoneNumber

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Race:(Checkallthatapply)

AmericanIndianorAlaskaNativeAsian

HawaiianNativeorOtherPacificIslander White

BlackorAfricanAmerican  Other

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PreferredMethodofContact

PhoneEmail

WeverifyallSocialSecurityNumbersthroughacomputermatchwiththeSocialSecurityAdministration.YourPandemicUnemploymentAssistanceapplication

andpaymentswilltakelongertoprocess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beused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

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C. ELIGIBILITYQUESTIONS

1. 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”,whatdatewereyouexpectedtostartwork?___________________

If“YES”,whatdatedidyournewjobclose?___________________

If“YES”,whatisthenameofthebusiness?_____________________________________

2. 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

3. Areyoureceivingorwillyoureceiveretirementpay(otherthanSocialSecurity)withinthenext12months? YESNO

If“YES”,whatisthenameoftheemployerthatmaintainedorcontributedtothisretirementplan?____________________________

4. HaveyoubeendiagnosedwithCOVID–19,orareyouexperiencingsymptomsofCOVID–19andseekingamedicaldiagnosis? YESNO

If“YES”,whatdatewerediagnosedorwhendidyoubeginexperiencingsymptoms?___________________

5. HasamemberofyourhouseholdbeendiagnosedwithCOVID–19? YESNO

If“YES”,whatdatewasthehouseholdmemberdiagnosed?___________________

PandemicUnemploymentAssistanceApplication 877 FormUIPUB81PUA(Page2of5)

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6. AreyoucaringforafamilymemberoramemberofyourhouseholdwhohasbeendiagnosedwithCOVID–19? YESNO

If“YES”,whatdatewasthefamilymemberormemberofyourhouseholddiagnosed?___________________

7. Isthereachildorotherpersoninthehousehold,forwhomyouhavetheprimarycaregivingresponsibilityfor,who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”,whatisthenameofthefacilitythatclosed?_____________________________________

If“YES”,whatdatedidthefacilityclose?___________________

8. 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”,whatdatedidyoubecometheproviderforahousehold?___________________

9. HasyourplaceofemploymentclosedasadirectresultoftheCOVID–19publichealthemergency? YESNO

If“YES”,whatdatedidyourplaceofemploymentclose?___________________

If“YES”,whatisthenameofthebusiness?_____________________________________

10. HaveyouquitajobasadirectresultofCOVID–19? YESNO

If“YES”,whatdatedidyouquit?___________________

If“YES”,whatisthenameofthebusiness?_____________________________________

If“YES”,didyouquitasadirectresultofCOVID‐19? YESNO

11. 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”,whatdatedidyoubecomeunabletoreachyourplaceofemployment?___________________

If“YES”,wereyouunabletoreachyourplaceofemploymentasadirectresultofCOVID‐19?  YESNO

12. 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”,whatdatedidyoubecomeunabletoreachyourplaceofemployment?___________________

If“YES”,wereyouunabletoreachyourplaceofemploymentasadirectresultofCOVID‐19? YESNO

13. Doyouhavetheabilitytocontinuetoreceivepaymentfromyouremployerwhileworkingfromhome? YESNO

If“YES”,wereyouunabletoacceptteleworkfromyouremployerbecauseofCOVID‐19? YESNO

14. Areyoureceivingpaidsickleaveorotherpaidleavebenefits? YESNO

If“YES”,whatdatedidyoubeginreceivingpaidsickleaveorpaidleavebenefits?___________________

If“YES”,whoareyoureceivingthispaymentfrom?_____________________________________

If“YES”,whatdatewillyourpaymentsend(ifknown)?___________________

15. Areyoucurrentlyself‐employed? YESNO

If“YES”,youMUSTanswerthequestionsinsectionD. 

D. SELF‐EMPLOYMENTINFORMATION

16. Atthetimeofthepandemic,wasthisself‐employmentyourprimaryoccupationandprimarymeansoflivelihood? YESNO

If"NO",explain. 

17. Whatservicesdidyouperform? 

18. Doyouhaveabusinessname? YESNO

If“YES”,whatisyourbusinessname?____________________________________________________

19. Doyoufileabusinessreturn?(Ex:ScheduleC,1120ora1065) YESNO

If“YES”,pleaselistwhatreturnsyoufile:

Form1040or1040‐SRScheduleC,ProfitorLossFromBusiness Form1120,U.S.CorporationIncomeTaxReturn

Form1040or1040‐SRScheduleF,ProfitorLossFromFarming Form1120‐S,U.S.IncomeTaxReturnforanSCorporation

Form1065,US.ReturnofPartnershipIncome Other:____________________________________________

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20. Doyoudeterminehowtheworkistobeperformed? YESNO

PandemicUnemploymentAssistanceApplication 877 FormUIPUB81PUA(Page3of5)

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21. Doyouhavetherighttohiresomeonetohelpyouperformyourservices? YESNO

If“YES”,canyoudischargethem? YESNO

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22. Doyoudeterminewheretheworkisgoingtobeperformed? YESNO

23. Doyoudetermineyourrateofcompensation? YESNO

24. Doyouhaveaninvestmentintools,equipment,etc.? YESNO

If“YES”,howmuch?___________________

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25. Canthecompanyyouprovideservicestoterminateyou? YESNO

26. 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

   

Fortheweeksclaimedabove,answerthefollowingquestionsbycheckingtheappropriatebox(es)andorprovidingtheadditionalinformationrequested.

27. Didyouapplyfororreceive: 

a. Anyinsurancepaymentsforlossofwagesduetoillnessordisability? YESNO



If“YES”,TypeofPayment:___________________________________________

PeriodCovered:From______________________to______________________



b. Anypaymentsfromprivateincomeprotectioninsurance? YESNO



If“YES”,TypeofPayment:___________________________________________

PeriodCovered:From______________________to______________________



c. Anypaymentsofasupplementalunemploymentbenefit? YESNO



If“YES”,TypeofPayment:___________________________________________

PeriodCovered:From______________________to______________________



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



If“YES”,TypeofPayment:___________________________________________

PeriodCovered:From______________________to______________________



28. Areyouableandavailableforworkduringthisweekbasedonourstaterequirements? YESNO



29. AreyoucaringforafamilymemberoramemberofyourhouseholdwhohasbeendiagnosedwithCOVID‐19? YESNO



30. HaveyoubeendiagnosedwithCOVID‐19,orareyouexperiencingsymptomsofCOVID‐19andseekingmedicaldiagnosis? YESNO



31. HasamemberofyourhouseholdbeendiagnosedwithCOVID‐19? YESNO



32. Isthereachildorotherpersoninthehouseholdforwhomyouhavetheprimarycaregivingresponsibilitywhoisunabletoattendschool

thatclosedasadirectresultofCOVID‐19?

YESNO



33. Isthereachildorotherpersoninthehouseholdforwhomyouhavetheprimarycaregivingresponsibilitywhoisunabletoattenda

facilitythatclosedasadirectresultofCOVID‐19?

YESNO



34. Haveyoubecomethebreadwinnerorproviderofmajorsupportforahouseholdbecausetheheadofhouseholdhasdiedasadirect

resultofCOVID‐19?

YESNO



PandemicUnemploymentAssistanceApplication 877 FormUIPUB81PUA(Page4of5)



35. Areyouunabletoreachyourplaceofemploymentbecauseyouhavebeenadvisedbyahealthcareprovidertoself‐quarantinedueto

concernsrelatedtoCOVID‐19?

YESNO



36. 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



37. WereyouscheduledtostartanewjobthathassinceclosedorcurtailedoperationsduetothedirectresultoftheCOVID19publichealth

emergency?

YESNO



If“YES”,hasyouremployercalledyoubacktowork? YESNO



If“YES”,didyoureturntowork? YESNO



38. HasyourplaceofemploymentclosedorcurtailedoperationsasadirectresultoftheCOVID‐19publichealthemergency? YESNO



If“YES”,hasyouremployercalledyoubacktowork? YESNO



If“YES”,didyoureturntowork? YESNO



39. DidyouquitworkasadirectresultoftheCOVID19publichealthemergency YESNO



40. Didyourefuseanyworkduringthisweek? YESNO



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

$0in‐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.

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.

PandemicUnemploymentAssistanceApplication 877 FormUIPUB81PUA(Page5of5)



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:

SecureUpload:athttps://secure.emp.state.or.us/ocs4/.

Mail:OregonEmploymentDepartmentPOBox14165Salem,OR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.

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