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The disaster declared by President Biden on Jan. (Washington)

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Disaster Unemployment Assistance PO Box 19019 Olympia, WA 98507-0019 855-952-9988
Dear Applicant,
The disaster declared by President Biden on Jan. 5, 2022, and amended on Jan. 27, 2022, was due to the
flooding and mudslides that occurred from Nov. 5 through Dec. 2, 2021 (FEMA-4635-DR). The
designated disaster counties are Clallam, Skagit and Whatcom, and include tribal lands held by the
Lummi Nation, Nooksack Indian Tribe and Quileute Tribe.
Apply for regular unemployment benefits first
You must apply for regular unemployment benefits and be denied before you can apply for DUA. The
best way to apply for regular unemployment benefits is through eServices at esd.wa.gov 24 hours a day,
seven days a week.
If you don’t have an eServices account or can’t access eServices, you can apply for regular
unemployment benefits by phone. Use the automated voice application by calling the Unemployment
Claims Center at 800-318-6022.
After you apply for unemployment, submit your DUA application.
Two ways to apply for DUA
You can apply for DUA and submit your weekly claims using the paper forms in this packet or by
speaking to an agent at our DUA Unit at 855-952-9988. You can also call this number if you have
questions about the application process.
To apply using paper forms
Your Disaster Unemployment Assistance (DUA) packet includes:
• Information sheet
• DUA application
• Application instructions
• DUA weekly claim form
• Weekly claim instructions
• Request for Taxpayer Identification Number and Certification (W-9) and instructions
• For those who were self-employed or who worked in non-covered employment at the time of the
disaster:
• Supplement to DUA application for self-employed individuals.
Disaster Unemployment Assistance PO Box 19019 Olympia, WA 98507-0019 855-952-9988
Please read all instructions carefully. After you complete the forms, submit them on our website,
by fax, phone, or by postal mail:
• Online: Go to esd.wa.gov/dua and look for the secure upload link.
• Fax: 844-395-6712.
• Mail:
Employment Security Department
Disaster Unemployment Assistance
PO Box 19019
Olympia, WA 98507-0019
If you have questions, call the Disaster Unemployment Assistance Unit at 855-952-9988.
Deadlines
Your completed application must be received by fax or postmarked no later than Mar. 9, 2022. If your
application is received or postmarked after that date, you must show a good reason for submitting late.
What to expect
Please allow 10 to 15 working days for us to process your application. We will notify you by mail when
we approve or deny your application.
More information for those who were self-employed
If you were self-employed at the time of the disaster, or at any time during the 24 months before the
disaster, you must complete the “Supplement to DUA application for self-employed individuals”
included in this packet.
You must also include a copy of your federal income tax return (Form 1040 plus Schedule C, F, SE or
K).
• Submit your 2020 tax return if you became unemployed due to the flooding in 2021.
• Submit your 2021 tax return if you became unemployed due to the flooding in 2022.
• The return needs to show your net income from self-employment for that tax year.
If those documents were lost in the disaster or are unavailable, contact the DUA Unit.
If you have any questions, please contact the DUA Unit at 855-952-9988.
Disaster Unemployment Assistance PO Box 19019 Olympia, WA 98507-0019 855-952-9988
What is Disaster Unemployment Assistance?
Disaster Unemployment Assistance (DUA) gives financial help to people whose jobs or self-employment
were lost or interrupted as a direct result of a major disaster. The disaster must be formally declared by the
President of the United States. The Washington State Employment Security Department administers the
program on behalf of the federal government.
Who is eligible?
Unfortunately, losing property or crops does not automatically make you eligible for DUA. It’s generally
available if you lived or worked in the affected areas, and due to the disaster, one or more of these situations
apply. You:
• No longer have a job or place to work.
• Can’t reach your workplace.
• Can’t work due to damage at your workplace.
• Can’t work because of an injury caused by the disaster.
• Couldn’t start a job you were scheduled to start.
• Became the head of your household because the former head of the household died due to the
disaster.
You must also:
• Be legally authorized to work in the United States.
• Not qualify for regular unemployment benefits from any state or a railroad company.
• Apply by the deadline for DUA related to the Northwestern Washington flooding and mudslides
(FEMA-4635-DR).
o Your application must be postmarked or faxed by Mar. 9, 2022.
o We may still accept your application if you have a good reason for filing late.
How do I apply?
You can:
• Download the application packet from esd.wa.gov/dua
. Then fax, mail or submit on the website.
• Visit your local WorkSource office. Use computers there for free or ask staff for help.
• Call our Disaster Unemployment Assistance Unit at 855-952-9988. An agent will take your
information.
How much will I get paid each week?
The amount we’ll pay you is based on your previous earnings. After you apply, we’ll send you a letter by
mail, telling you how much you are eligible to receive. You could receive a weekly benefit amount between
$231 and $929, with some exceptions for part-time workers.
If you don’t provide documents verifying your income within 21 days of submitting your application, your
weekly benefit amount may change.
• If you became unemployed due to the disaster in 2021, provide documents for 2020.
• If you became unemployed due to the disaster in 2022, provide documents for 2021.
Disaster Unemployment Assistance PO Box 19019 Olympia, WA 98507-0019 855-952-9988
How long will I get benefits?
Disaster Unemployment Assistance is payable for weeks you continue to be unemployed as a direct result of
the disaster between Nov. 7, 2021, and July 9, 2022.
Where can I get more information?
• Go to our website at esd.wa.gov/dua.
• Call our DUA Unit at 855-952-9988.
Disaster Unemployment Assistance PO Box 19019 Olympia, WA 98507-0019 855-952-9988
How to complete your
Disaster Unemployment Assistance (DUA) application
Please read these instructions carefully before completing your application to avoid any processing
delays.
• Write legibly.
• Complete all information.
Apply for regular unemployment benefits first
You must apply for regular unemployment benefits and be denied before you can apply for DUA. The
best way to apply for regular unemployment benefits is through eServices at esd.wa.gov 24 hours a day,
seven days a week.
If you don’t have an eServices account or can’t access eServices, you can apply for regular
unemployment benefits by calling the Unemployment Claims Center at 800-318-6022 during normal
business hours.
After you submit your application for regular benefits, submit your DUA application.
What to include in your DUA application
• The application.
• Acceptable income and employment documents. See the list included in the application packet.
• The W-9 Form.
• If you were self-employed at the time of the disaster, also include the Supplement to DUA
application for self-employed individuals.
When will you be paid?
DUA benefits can be paid when:
1. We have established you are not eligible for regular unemployment.
2. We have established you are eligible for DUA
3. You have submitted a DUA weekly claim
This process could take a few days or a few weeks. You can help us by answering our calls for more
information.
Tips for completing the DUA application
Personal information section
Provide a physical mailing address where you can receive a paper check by postal mail. It is important
to use the same address on all application materials.
Disaster Unemployment Assistance PO Box 19019 Olympia, WA 98507-0019 855-952-9988
Complete all information unless it is marked optional.
If you are not a U.S. citizen or American national, you must:
• Certify that you have satisfactory immigration status.
• Provide your alien registration number and expiration date.
We might ask you to send a clear copy of the front and back of your Alien Registration Card (ARC).
Section A. Unemployed worker due to disaster
Explain in detail how the disaster directly caused your unemployment. Your written explanation will
help us decide if you are eligible for DUA. Include as much specific information as possible.
If you answer Yes to any of the questions, you must provide more information in Section G. The
additional information you provide will help us determine your eligibility. If you do not provide
additional information, we may have to call you to ask additional questions.
Section B. Work history
Starting with your most recent job, list all of your employment or self-employment for the 24-months
before the disaster. Enclose copies of your W-2 forms or pay stubs from each employer listed. If you are
or were self-employed, enclose a copy of Schedule C, F, SE or K with Form 1040.
If you can’t give us copies of the documents immediately but will be able to soon, or if the documents
were destroyed in the disaster, provide that information in Section G.
Section D. Self-employed – not working for another employer
Complete the form “Supplement to DUA application for self-employed individuals.” Include a
copy of Schedule C, F, SE or K with your Form 1040.
Section E. Other compensation
If you answer Yes to any of the questions, you must provide more information in Section G.
Section F. Self-employment and non-covered employment income
The information in this section will be used to determine your weekly benefit amount. Most employers
have already reported wages to ESD, but if you are self-employed or worked in non-covered
employment, we will not have a record of that information and you should provide it here. If we don’t
have a record of your income and you don’t provide documentation, you are only eligible for the
minimum benefit amount.
If you are both self-employed and employed by someone else, report your self-employed income in this
section.
Disaster Unemployment Assistance PO Box 19019 Olympia, WA 98507-0019 855-952-9988
Use this section to report your income for the 2020 or 2021 tax year.
• If you became unemployed due to the disaster in 2021, provide documents for 2020.
• If you became unemployed due to the disaster in 2022, provide documents for 2021.
Section G. Remarks
Use this space to write more about questions you answered with Yes and were marked with an asterisk
(*). You also can use this section if you need more space to answer any question.
Section H. Applicant certification and signature
We are required by federal law to include this statement. Please read it carefully before signing and
dating the application. If you don’t sign and date the application, we’ll have to return it to you and your
benefit payments will be delayed.
Submit your application and supporting documents, on our website, by fax or postal mail:
• Online: Go to esd.wa.gov/dua and look for the secure upload link.
• Fax: 844-395-6712.
• Mail:
Employment Security Department
Disaster Unemployment Assistance
PO Box 19019
Olympia, WA 98507-0019
If you have questions or would like to apply by phone, call the Disaster Unemployment Assistance Unit
at 855-952-9988.
1 EMSX 5712 (Rev. 2/2022)
DISASTER UNEMPLOYMENT ASSISTANCE
APPLICATION
Disaster No.: FEMA - 4635 - DR
Explain answers to questions with an asterisk (*) on page 3, section G, “Remarks.”
Personal information Date completed: _____________________
Last name, first name, middle initial:
Social Security number:
Mailing address:
Phone number:
City:
State:
Gender (choose one):
Male Other Female
Date of birth:
Month _____ D
ay _____ Year _____
County of residence:
Race/ethnicity (optional)
White, not Hispanic Black, not Hispanic Hispanic
American Indian/Alaska Native Asian/Pacific Islander Other
Email address (if applicable):
By providing an email address, you consent to us contacting you with confidential information by email.
Are you a U.S. Citizen or American
National?
Yes No
If not a U.S. Citizen or American National,
do you certify that you have satisfactory
immigration status?
Yes No
If you have satisfactory immigration status, attach a copy of your
Alien Registration Card (ARC) and provide the following:
Alien number: _________________________________________
Expiration date: ________________________________________
Unemployment benefits are taxable income. You can choose to have 10% of your weekly benefit payments deducted for federal income tax.
Please indicate your choice: Yes I request 10% of my weekly benefit payments be deducted for income tax.
No I do not want 10% of my weekly benefit payments to be deducted for income tax.
A. Unemployed worker due to disaster:
Explain in detail how this disaster was the direct cause of your unemployment. Attach additional paper, if necessary.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
1. Check your main source of income or livelihood at the time of the disaster*:
Employment Retirement pay/Pension Self-employment Other _________________________________
2. What date did you become unemployed as a direct result of the disaster? Month ______ Day ______ Year ______
3. Have you applied for unemployment benefits with any state, federal or railroad program? ................................. Yes* No
4. Are you eligible to collect unemployment with any state, federal or railroad program in the last year? ............. Yes* No
5. Were you injured as a direct result of the disaster? ............................................................................................... Yes* No
6. Did you become the head of household due to a death caused by the disaster? ................................................... Yes* No
B. Work history
List all employment for the last 24 months and include a copy of the W-2 forms from your employer(s). List all self-employment during the last
24 months. Attach additional pages if necessary and be sure to include all details on those additional pages.
Last employer/self-employment:
Date started:
Date last worked:
County of job location:
Did you work:
Full-time; or
Part-time?
Address:
City/State/Zip:
Occupation:
Last employer/self-employment:
Date started:
Date last worked:
County of job location:
Did you work:
Full-time; or
Part-time?
Address:
City/State/Zip:
Occupation:
Last employer/self-employment:
Date started:
Date last worked:
County of job location:
Did you work:
Full-time; or
Part-time?
Address:
City/State/Zip:
Occupation:
*Explain in “Remarks” section on page 3.
2 EMSX 5712 (Rev. 2/2022)
C. Employer at the time of disaster
Complete this section if you were working for any employer, not self-employment, at the time of the disaster.
1. Were you working for an employer, other than self-employment, as your primary source of income
at the time of the disaster?
Yes No
If “Yes:”
Employer’s name:
Street address
of job site:
City: State: Zip:
What date did you become unemployed as a direct result of the disaster?
Employer’s phone:
Month _______ Day _______ Year _______
Occupation:
2. Did the
disaster prevent you from reaching your place of employment?
Yes No
If “Yes:”
How were you prevented:
When wer
e you unable to reach work? From:
To:
3. Did your employer close as a direct result of the disaster?
Yes No
If “Yes:”
Reason for closure:
Date comp
any closed:
Date compa
ny reopened or will reopen:
4. Did the disaster prevent you from starting a new job with an employer? Yes No
If “Yes:”
Employer’s name:
Street address
of job site:
City: State: Zip: Employer
’s phone:
Person who offered you the job: Title:
Date you were scheduled to
start:
Reason you could not start: Unable to get to job Business closed Other* __________________________________
D. Self-empl
oyed – not working for another employer.
Complete the enclosed form “Supplement to Disaster Unemployment Assistance Application for Self-Employed Individuals.”
Include a copy of Schedule C, F, SE or K with your Form 1040.
E. Other compensation
Have you applied for or are you receiving any of the following: Monthly amount
From
(Mo/Day/Yr)
To
(Mo/Day/Yr)
State, federal, or railroad unemployment benefits?
Yes* No
$____________ __________ __________
Loss of wages due to illness or disability (worker’s compensation)?
Yes* No
$____________ __________ __________
Private income protection or supplemental unemployment benefits?
Yes* No
$____________ __________ __________
Vacation, sick, or holiday pay?
Yes* No
$____________ __________ __________
Retirement pay or pension (list what kind in “Remarks”)? Do not
include Social Security benefits.
Yes* No
$____________ __________ __________
Any other income?
Yes* No
$____________ __________ __________
*Explain in “Remarks” section on page 3.
3 EMSX 5712 (Rev. 2/2022)
F. Self-employment and non-covered employment income
Income that counts when calculating your Disaster Unemployment Assistance benefit amount may include earnings:
• From your own business.
• As an independent contractor.
• From employers that don’t report your wages to us for unemployment purposes, such as certain religious organizations (called non-covered
employment).
Report your earnings after your reasonable business expenses have been deducted from your gross income if you are self-employed. Please
consult your accountant, tax advisor or other financial professional if you are unsure what these amounts are.
If you worked in non-covered employment, report your gross wages before deductions.
To provide your earnings:
1. Fill in the boxes below for each quarter; and
2. Attach your documents for proof of income. See detailed instructions and a list of acceptable documents.
There could be a delay receiving the correct weekly benefit amount if there are discrepancies between the income shown on your documents and
the amounts you provided in the boxes.
If you became unemployed due to the disaster in 2021, enter the amount you made in 2020.
If you became unemployed due to the disaster in 2022, enter the amount you made in 2021.
Jan - Mar
Net Earnings
Apr - Jun
Net Earnings
Jul - Sep
Net Earnings
Oct - Dec
Net Earnings
Attach documentation of your self-employment or non-covered earnings so we can make a final decision on your claim. Only submit documents
from the list of acceptable documents. Please ensure that the amounts you enter as “Net Earnings” in the boxes above match as closely as
possible to the corresponding amounts on your documents.
You must provide documents within 21 days of submitting this application if you currently do not have them available.
G. Remarks -- Provide any remarks for questions marked with an asterisk (*):
You can attach additional pages if needed.
H. Applicant certification and signature
I certify that all of the information I have given on this application, and forms related to this application, is correct to the best of my
knowledge and belief, and that I have supplied this information in order to obtain Disaster Unemployment Assistance. I understand
that federal funds are provided and that under 18 U.S.C. 1001 I may be subject to prosecution for willfully concealing material facts or
knowingly making a false statement to obtain Disaster Unemployment Assistance to which I am not entitled. I am furnishing my
Social Security number as required under 26 U.S.C. 6109(d) for purposes of reporting DUA as federal taxable income and for
determining my entitlement to Disaster Unemployment Assistance. I understand, in accordance with 20 CFR 625.16(b), that
information concerning my Disaster Unemployment Assistance application may be disclosed only as is allowed with respect to regular
compensation under state law and to the U.S. Department of Labor.
Signature of applicant: ________________________________________________________ Date: ___________________
EMSX 5712-SE (Rev. 2/2022)
SUPPLEMENT TO DISASTER UNEMPLOYMENT
ASSISTANCE APPLICATION FOR SELF-
EMPLOYED INDIVIDUALS
Disaster No.: FEMA - 4635 - DR
Include a copy of Schedule C, F, SE, or K with your Form 1040.
Applicant name (last, first, middle initial):
Social Security number:
Business name:
Is your self-employment in farming?
Yes No
Street address:
City:
State:
Zip Code:
County:
Are you a sole proprietor or a partner?
Sole proprietor Partner
County of residence:
County of job location:
A. Farming activity (if applicable)
List all farm products raised and held primarily for sale in columns below.
Crop(s) Livestock Other (specify)
Kind Acres Kind Quantity Kind Quantity
B. Self-employment information
1. What kind of self-employment do you perform and how long have you performed it?
2. Were you actively engaged in self-employment at the time of the disaster?
If “No,” please explain:
Yes No
3. Did the disaster prevent you from performing all activities associated with your self-employment?
If “No,” what activities were you still able to perform?
Yes No
4. Have you been able to perform any activities which would enable you to resume your self-employment since
becoming unemployed?
If “No,” please explain.
Yes No
5. Was this self-employment your primary source of income and livelihood at the time of the disaster?
If “No,” please explain:
6. Did you work in self-employment as part of a family unit?
If “Yes,” please explain:
Yes No
Yes No
C. 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 Disaster
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.
Signature: Date:
Documents required for Disaster Unemployment Assistance application
To be eligible for Disaster Unemployment Assistance, you must send us proof that you:
• Worked for an employer before the November 2021 disaster.
or
• Worked in self-employment before the November 2021 disaster.
or
• Were scheduled before the November 2021 disaster to start a new job for an employer or in
self-employment.
If you worked for an employer before the November 2021 disaster
Include with your application your 2020 or 2021 federal income tax return.
• Submit your 2020 tax return if you became unemployed due to the disaster in 2021.
• Submit your 2021 tax return if you became unemployed due to the disaster in 2022.
AND submit at least one item from this list:
• Pay stub or earnings statement from the job you held when the November 2021 disaster
occurred.
• Name, address and phone number of your employer(s) when the disaster occurred.
• Letters or messages from the employer(s) if the messages include information such as:
o Earnings statement.
o Employer’s name and address.
o The start date, hours, rate of pay or duration of the job.
We might also ask you to send us the names and addresses of two people who can attest that you are
unemployed due to the disaster.
If you were self-employed before the November 2021 disaster
Include with your application your 2020 or 2021 federal income tax return with Schedule C, F, K or SE.
The return needs to show your net profit or loss.
• Submit your 2020 tax return if you became unemployed due to the disaster in 2021.
• Submit your 2021 tax return if you became unemployed due to the disaster in 2022.
AND submit at least one item from this list:
• Property titles or deeds for your place of business.
• Rental agreement or letter from a property owner showing when you occupied the place of
business.
• State tax registration or recent sales tax return
• Phone, utility or insurance bills showing your name and the address of the place of business.
• Business records or other evidence to verify that you were self-employed.
If you were scheduled before the November 2021 disaster to begin a new job for an
employer or in self-employment
Include with your application your 2020 or 2021 federal income tax return.
• Submit your 2020 tax return if you became unemployed due to the disaster in 2021.
• Submit your 2021 tax return if you became unemployed due to the disaster in 2022.
Also include with your application letters or messages from the prospective employer(s). Messages
should include:
o Name and address of prospective employer or your prospective place of self-
employment.
o The start date, hours, rate of pay or duration of the prospective job.
o The reason you didn’t start work for the prospective employer or in self-employment.
o The date you were scheduled to occupy your place of self-employment.
How to complete your W-9 Form
In order for us to issue your benefit payment, you must complete this form.
If you are self-employed, complete the W-9 as an individual, not as a corporation or
business.
Box 2 - Business name: Leave this blank if your business name is the same as your legal
name.
Box 3 - Internal Revenue Service reporting type: To avoid errors, we have already
marked this for you. The first box should be checked. Do not check any other boxes.
Box 4 - Exemptions: Leave blank. Individuals are not eligible for exemptions.
Line 7 - Taxpayer Identification number: Enter your Social Security number – not
your Employer Identification number.
Line 8 - Certification: Signature and date, either electronic or handwritten.
Submit your W-9 form with your DUA application packet online, by fax or
by postal mail.
 
• Online: Go to esd.wa.gov/dua and look for the secure upload link.
• Fax: 844-395-6712.
• Mail:  
Employment Security Department 
Disaster Unemployment Assistance 
PO Box 19019 
Olympia, WA 98507-0019 
 
If you have questions or to complete this form with an agent by phone, call the Disaster
Unemployment Assistance Unit at 855-952-9988.
Revised 2/2/22
Complete and sign the Request for Taxpayer Identification Number (W-9)
Substitute
Form
W-9
Request for Taxpayer
Identification Number and Certification
1. Legal name (as shown on your income tax return):
2.Business name, if different from legal name above – e.g. Doing Business As (DBA) name:
3.Check ONLY ONE box below (see W-9 instructions for additional information)
Individual,
Sole Proprietor, or
single-member
LLC
Partnership
Corporation
S-Corp
LLC filing as
Corporation
LLC filing as
Partnership
LLC filing as S-Corp
Nonprofit organization
Volunteer
Board/Committee
member
Local Government
State Government
Federal Government
(including tribal)
Tax-exempt organization
Exempt payee
Trust/Estate
4. Exemptions (codes apply only to certain entities, not individuals):
Exempt payee code (if any):
Exemption from FATCA reporting code (if any):
5. Address (number, street, and apt. or suite no.)
For office use
6. City, state, and ZIP code
7.Taxpayer Identification
Number (TIN)
Enter your EIN OR SSN in the
appropriate box to the right (do
not enter both).
For individuals, this is your social
security number (SSN).
For other entities, it is your
employer identification number
(EIN).
Social security number
-
-
OR
Employer identification number
-
Note: The EIN or SSN must match the Legal Name as reported to the IRS. For a resident alien, sole proprietor or
disregarded entity, or to find out how to get a Taxpayer Identification Number, see the W-9 Instructions. If the account
is in more than one name, see the W-9 Instructions for guidelines on whose number to enter.
8. Certification
Under penalty of perjury, I certify that:
•
The number shown on this form is my correct taxpayer identification number (or I am waiting for a
number to be issued to me), and
•
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I
have not been notified by the Internal Revenue Service (IRS) that I am subject to backup
withholding as a result of a failure to report all interest or dividends or (c) the IRS has notified me
that I am no longer subject to backup withholding, and
•
I am a U.S. person (including a U.S. resident alien); and
•
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting
is correct.
(For additional information about the W-9 see the W-9 Instructions.)
SIGNATURE of U.S. PERSON
Date
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