Claimant Name First Name Last Name Address Street Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code / Zip Code Email Phone Docket Number(s) Please answer all of the following questions. Some of the questions may have been asked during the Employment Security Department’s investigation. Please answer the questions here, even if you answered the same questions before. The following questions are about the period you were unemployed or partially unemployed (in other words, the period you are requesting benefits for). 1. Is the person filling out this form the same person listed above? Yes No 1. Person filling out not same as above fieldset Name of person filling out this form Age of person filling out this form Relation to Claimant 2. Did you suffer from any sicknesses or injuries that kept you from working full time? Yes No Please give details about (i) your sickness and/or injuries, and (ii) when or if you have recovered enough to perform full time work. 3. Did you have adequate transportation to look for and get to work? Yes No Please give details about (i) your transportation problems, and (ii) when or if those transportation problems got resolved. 4. Do you care for anyone else (minor child, sick spouse, elder parent) that would keep you from performing full time work? Yes No 4. Care for someone else which keeps from performing full time work fieldset Who were you caring for? When did that care begin? Are you still caring for them? 5. Were you a full time student during this period? Yes No 5. Full time student fieldset What type of academic program were you enrolled in? What was your academic schedule? What is your customary profession? What are the hours of your customary profession? If you were offered full time work which conflicted with your academic schedule, could you change your class schedule? Yes No Would you be willing to drop your classes to accept full time work if the offered work conflicted with your academic schedule? Yes No 6. Did you perform at least the minimum required work searches for each of the weeks you have been requesting benefits, starting the week of July 4, 2021? Yes No If requested, could you provide a list of those job searches? Yes No What weeks did you not perform the minimum required work searches? For any week where you did not perform the minimum required work searches: 6a. Were you a member of a Union? Yes No 6a. Member of Union Name of Union: Were you a member in good standing? Yes No Were you available for dispatch during the weeks claimed? Yes No 6b. Were you employed? Yes No 6b. Employed Fieldset Name of employer: Dates of employment: Were your hours temporarily reduced during this period? Yes No. My employer did not have any work for me during this period. If yes, I usually work (number of hours) per week My schedule was reduced to (number of hours) per week Did you return to work? Were your hours increased to your usual schedule? Please explain 6c. Did you accept an offer of work? Yes No 6c. Accept offer of work fieldset Name of employer: What date was the offer of employment made? What date did the new employer offer for you to start work? What date did you start work with the new employer? Provide a copy of your written offer of work, if there was one. Documents can be provided by mail, fax, or through OAH’s participant portal. 6d. Were you employed, but temporarily stopped working? Yes No 6d. Were you employed fieldset Why did you stop working? When did you stop working? When did you or do you expect to resume work for your employer? 6e. Were you participating in full time training, with written approval of the Employment Security Department? Yes No If yes, provide a copy of your Commissioner Approved Training (CAT) Determination Letter. Documents can be provided by mail, fax, or through OAH’s participant portal. 7. Were there any other reasons you were not able or available for full time work? Yes No Please describe what those reasons are in detail. 8. Please include any additional information you wish the judge to know about this case: I declare under penalty of perjury under the laws of the state of Washington that the facts I have provided on this form are true. I agree. Submit Leave this field blank
