Fillable ZNu0VEPDQHKBiuQNI7XT PUA Weekly Request - English

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ZNu0VEPDQHKBiuQNI7XT PUA Weekly Request - English

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PandemicUnemploymentAssistanceWeeklyRequest 878 FormUIPUB83PUA(04‐20)
WEEKLYREQUESTFOR
PANDEMICUNEMPLOYMENTASSISTANCE(PUA)
ClaimantName(Last,First,Middle)
WeekClaimed
WeekDates
CustomerIdentification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outof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. 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
3. AreyoucurrentlyimpactedbytheCOVID‐19publichealthemergency? YESNO
i. If“YES”,explain.
4. Didyourefuseanyworkduringthisweek? YESNO
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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ZNu0VEPDQHKBiuQNI7XT PUA Weekly Request - English

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Completed 8 May 2020

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