Fill - Free fillable PUA Application En 202004290907 PDF form

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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

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

a. If“NO”,areyoucurrentlyimpactedbytheCOVID‐19publichealthemergency?  YESNO

i. If“YES”,explain.



3. Didyourefuseanyworkduringanyoftheweeksclaimedabove?  YESNO

- 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

$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.

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.

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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PUA Application En 202004290907

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