BAP Pandemic Unemployment Assistance Declaration

Claimant Information
Claimant Name
Unemployment Assistance Declaration
I am the (check one)
I was denied regular state unemployment benefits.

During the weeks that I claimed Pandemic Unemployment Assistance (PUA) benefits, I could not work for the following COVID-19-related reasons (check all that apply):

1. I was diagnosed with COVID-19 or experiencing symptoms of COVID-19 and seeking a diagnosis.
2. A member of my household was diagnosed with COVID-19.
3. I was providing care for family or someone who lives with me who was diagnosed with COVID-19.
4. I had primary caregiving responsibilities for someone who usually attends a school or daycare facility that was closed because of COVID-19.
5. I was unable to reach my place of employment due to COVID-19 travel restrictions or quarantine.
6. I could not work because a health care professional told me to quarantine.
7. I was supposed to start work but could not due to COVID-19.
8. I became the main breadwinner for my household because the previous breadwinner died from COVID-19.
9. I had to quit my job as a direct result of COVID-19.
10. My workplace closed due to COVID-19.
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.
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.
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.
14. I was laid off, or my hours were reduced as a direct result of the COVID-19 health emergency.
Other than the reasons explained above, I was able and available to work full time during the weeks that I have claimed PUA benefits.
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.
I have not refused any offers of suitable work during a week I claimed PUA benefits.
I was not able to telework (work from home) for full pay with my last employer.
I could not receive full paid leave with my last employer.
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.