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PUA Weekly En 20200520

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BROWSE COLUMBIA GORGE COMMUNITY COLLEGE FORMS

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PandemicUnemploymentAssistanceWeeklyRequest 878 FormUIPUB83PUA(05‐20)
WEEKLYREQUESTFOR
PANDEMICUNEMPLOYMENTASSISTANCE(PUA)
ClaimantName(Last,First,Middle)(PleaseusenameonfilewiththeSocialSecurityAdministration)
WeekClaimed
WeekDates
CustomerIdentificationNumberorSocialSecurityNumber Beginning(Sunday) Ending(Saturday)
APPLICANTREQUEST
Youareclaimingbenefitsforthe“weekclaimed”(shownabove).YouareeligibleforPUAifyouareunemployed,unabletowork,orunavailablefor
workasadirectresultoftheCOVID‐19publichealthemergency.
Pleaseanswerthefollowingquestionsbycheckingtheappropriatebox(es)andorprovidingtheadditionalinformationrequested.
CompleteSectionAandCifyouworkedinself‐employmentduringtheweek.
GodirectlytosectionsBandCifyoudidnotworkinself‐employment.
A. Self‐Employment
1. Didyouperformanyworkrelatedtoyournormalself‐employmentduringthisweek? YESNO
GROSSPaymentReceived,whetherserviceswereperformedduringtheweekornot
$___________
2. WasthisworkperformedinanefforttoRESUMEyournormalself‐employmentactivity? YESNO
B. Employment
1. Ifyouwerenotself‐employed,didyoudootherworkduringtheweekclaimed? YESNO
2. NumberofHoursWorked
___________
3. GROSSAmountEarned,whetherpaymenthasbeenreceived
$___________
C. WeeklyEligibility
1. 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______________
2. Areyouableandavailableforworkduringthisweekbasedonourstaterequirements? YESNO
3. AreyoucaringforafamilymemberoramemberofyourhouseholdwhohasbeendiagnosedwithCOVID‐19? YESNO
4. HaveyoubeendiagnosedwithCOVID‐19,orareyouexperiencingsymptomsofCOVID‐19andseekingmedical
diagnosis?
YESNO
5. HasamemberofyourhouseholdbeendiagnosedwithCOVID‐19? YESNO
6. 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
7. 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
8. 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
9. 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
10. 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
PandemicUnemploymentAssistanceWeeklyRequest 878 FormUIPUB83PUA(05‐20)
11. 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
12. 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
13. DidyouquitworkasadirectresultoftheCOVID19publichealthemergency YESNO
14. Didyourefuseanyworkduringthisweek? YESNO
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
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theinformationTOANYSOURCEforpurposesauthorizedunderEmploymentDepartmentlaw.
Signature_________________________________________________ Date(Month,Day,Year)______________________
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PUA Weekly En 20200520

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Completed 24 May 2020

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