BAP PUA

Address

Street Address
Street Address 2
City	State
Postal Code	Country

Phone

Area CodePhone Number

I am (age) years old

Name and relation to claimant

Provide the date(s) and reason(s) for denial:

1. I was diagnosed with COVID-19 or experiencing symptoms of COVID-19 and seeking a diagnosis.

Yes

No

2. A member of my household was diagnosed with COVID-19.

Yes

No

3. I was providing care for family or someone who lives with me who was diagnosed with COVID-19.

Yes

No

4. I had primary caregiving responsibilities for someone who usually attends a school or daycare facility that was closed because of COVID-19.

Yes

No

5. I was unable to reach my place of employment due to COVID-19 travel restrictions or quarantine.

Yes

No

6. I could not work because a health care professional told me to quarantine.

Yes

No

7. I was supposed to start work but could not due to COVID-19.

Yes

No

8. I became the main breadwinner for my household because the previous breadwinner died from COVID-19.

Yes

No

9. I had to quit my job as a direct result of COVID-19.

Yes

No

10. My workplace closed due to COVID-19.

Yes

No

11. I am an independent contractor with reportable income and the COVID-19 public health emergency severely limited my ability to continue performing my customary work activities, and I was thereby forced to suspend such activities.

Yes

No

12. I refused to return to work for my employer or refused an offer of work because the worksite was not in compliance with local, state, or national health and safety standards related to COVID-19 such as face masks, providing personal protective equipment, or social distancing, and I was denied benefits as a result of the refusal.

Yes

No

13. I work for a school or educational service district and was unemployed or partially unemployed due to volatility in the work schedule as a direct result of COVID-19 such as schedule changes and/or partial closure.

Yes

No

14. I was laid off, or my hours were reduced as a direct result of the COVID-19 health emergency.

Yes

No

Other than the reasons explained above, I was able and available to work full time during the weeks that I have claimed PUA benefits.

Yes

No

During each week I claimed PUA benefits after July 4, 2021, I was actively searching for work or performing authorized work activities as required by state unemployment laws.

Yes

No

I have not refused any offers of suitable work during a week I claimed PUA benefits.

Yes

No

I was not able to telework (work from home) for full pay with my last employer.

Yes

No

I could not receive full paid leave with my last employer.

Yes

No

9. Please include any additional information you wish the judge to know about this case:

Washington State
Office of Administrative Hearings

Pandemic Unemployment Assistance Declaration