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REEMPLOYMENT ASSISTANCE PUA CLAIMANT: BACKDATE AND LATE FILING (South Dakota DLR)

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South Dakota Department of Labor & Regulation (DLRA) aim to promote economic opportunity and financial security in the South Dakota. They support individuals and businesses through expert services, employment solutions and business practices.

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SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION
REEMPLOYMENT ASSISTANCE
P.O. Box 4730, Aberdeen, SD 57402 Fax: 605.626.3172 raclaims.sd.gov
PUA CLAIMANT: BACKDATE AND LATE FILING REQUEST
CLAIMANT NAME: ____________________________________________ SSN: ________________________
Current Effective Date of Claim: ____________ Backdating Requesting Start Date of (must be a Sunday):__________
Effective date is on your monetary determination The Sunday after the first week
SECTION A: Week Ending Date:
(Saturday)
____________
MM/DD/YYYY
____________
MM/DD/YYYY
____________
MM/DD/YYYY
During the week that ended in that date in the row
above, did you work for an employer or in self-
employment? (If yes, add information for each employer on Pg 2)
YES NO
If no, skip to Section B
(Starts with Holiday Pay)
YES NO
If no, skip to Section B
(Starts with Holiday Pay)
YES NO
If no, skip to Section B
(Starts with Holiday Pay)
Total number of hours you worked during the week (with all
employers or self-employment):
_______ hrs
_______ hrs
_______ hrs
Gross wages earned in dollars and cents (If self-employed, use NET)
$ __________
$ __________
$ __________
If worked but had no earnings, was it because you
attempted commission sales, were self-employed, or
have other unpaid hours?
YES NO
YES NO
YES NO
Are you still working?
YES NO
YES NO
YES NO
SECTION B Did you or will you receive any of the following for this week?
HOLIDAY PAY?
YES NO
If yes, gross amount
YES NO
If yes, gross amount
YES NO
If yes, gross amount
VACATION PAY OR ANNUAL LEAVE?
YES NO
If yes, gross amount
YES NO
If yes, gross amount
YES NO
If yes, gross amount
SICK PAY?
YES NO
If yes, gross amount
YES NO
If yes, gross amount
YES NO
If yes, gross amount
SEVERANCE PAY/WAGES IN LIEU OF NOTICE?
YES NO
If yes, gross amount
YES NO
If yes, gross amount
YES NO
If yes, gross amount
Will you begin receiving pension, disability payments or
workers’ compensation or did the amount previously
reported change?
YES NO
If yes, explain in remarks
YES NO
If yes, explain in remarks
YES NO
If yes, explain in remarks
Are you on call to return to work for your regular employer?
YES NO
YES NO
YES NO
Were you physically and mentally able to work?
YES NO
if no, explain in remarks
YES NO
if no, explain in remarks
YES NO
if no, explain in remarks
Were you available to accept a job if offered?
YES NO
if no, explain in remarks
YES NO
if no, explain in remarks
YES NO
if no, explain in remarks
Did you refuse any offer of work or referral to work?
YES NO
If yes, explain in remarks
YES NO
If yes, explain in remarks
YES NO
If yes, explain in remarks
Did you begin school or did your class schedule change
during the week?
YES NO
YES NO
YES NO
For each week, identify the reason(s) that best describe
your situation from the list on the next page (Section C).
If “Other” (M) add reason on page 2.
You are responsible for reading and knowing the information in your claimant handbook about benefit eligibility. Attempting to claim or
receive benefits by entering false information could mean a loss of benefits, fine, and imprisonment. Please note you are agreeing to have
your responses become part of your account record and the information your provide may be verified through matching programs. Do you
understand? YES NO
CERTIFICATION: I certify that my statements are true and correct and I am aware of the penalties for all false statements on my claim.
Claimant’s Signature
____________________________________________________________ Date: _________________
BACKDATE
REQUEST ONLY
To e-sign this form, you will need to open it in an Adobe Reader (not a web browser) OR use your mobile device OR Print and sign in ink. Sending instructions are on Page
2. DLR – RA 320 PAGE 1 REV 06/12/2020
click to sign
signature
click to edit
DLR – RA 320 PAGE 2
Section C Reason that best describes your situation during the week requesting should be entered in the last box on
Page 1.
A = You tested positive or you are experiencing symptoms of COVID-19 and seeking a medical diagnosis.
B = A member of your household tested positive for COVID-19.
C = You are providing care to a family member or member of your household who has tested positive for COVID-19.
D = You are the primary caregiver for a child or other person who is unable to attend school or another care facility that is closed
as a direct result of COVID-19 and the school or facility is necessary in order for you to work.
E = You are unable to reach your place of employment because of a quarantine imposed as a result of COVID-19
F = You are unable to work because you have been advised by a health care provider to self-quarantine because of COVID-19.
G = You were scheduled to start a job and now do not have that job or are unable to reach that job because of COVID-19.
H = You have become the breadwinner or major support for a household because the head of household has died because of
COVID-19.
I = You have to quit your job because you were diagnosed with COVID-19 by a qualified medical professional, and although you
no longer have COVID-19, the illness caused health complications that render you objectively unable to perform essential job
functions, with or without a reasonable accommodation.
J = Your place of employment closed because of COVID-19.
K = Your employer reduced your hours of work because of COVID-19.
L = You are self-employed or an independent contractor and now unable to work because COVID-19 has severely limited your
ability to continue performing your customary work activities.
M = Other:
Section D If you have worked during this week, complete the information below. If you need more employers,
use the remarks box.
Employer Name:___________________________________________________________________ Still Working? YES NO
Worked: ______hrs for week: ___________ And ______ hrs for week: _________. And ______ hrs for week: _________
(week end date) (week end date) (week end date)
Wages: Hourly Rate:
___________ Total Wages (including tips):
__________
Employer Address:____________________________________________________________________________________________
Employer Name:___________________________________________________________________ Still Working? YES NO
Worked: ______hrs for week: ___________ And ______ hrs for week: _________. And ______ hrs for week: _________
(week end date) (week end date) (week end date)
Wages: Hourly Rate:
___________ Total Wages (including tips):
__________
Employer Address:____________________________________________________________________________________________
REMARKS: Reason for requesting backdating or late payment request. (Attach additional sheet if necessary):
Send Completed Form to: Mail Email: DLRRAClaims@state.sd.us
DLR RA Benefits *Note there are two R’s in this email address
PO Box 4730
Aberdeen SD 57402-4730
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REEMPLOYMENT ASSISTANCE PUA CLAIMANT: BACKDATE AND LATE FILING (South Dakota DLR)

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Completed 21 August 2020

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