Claimant Information 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 Email Phone Docket Number(s) I am (age) years old Unemployment Assistance Declaration I am the (check one) Claimant Other (relationship to the people in this case) Name and relation to claimant I was denied regular state unemployment benefits. Yes No Provide the date(s) and reason(s) for denial: 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. Yes No Provide dates of symptoms and any test results: 2. A member of my household was diagnosed with COVID-19. Yes No Provide dates, name(s), and relationship to you: 3. I was providing care for family or someone who lives with me who was diagnosed with COVID-19. Yes No Provide dates, name(s), and relationship to you: 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 Provide dates, name(s), and relationship to you: 5. I was unable to reach my place of employment due to COVID-19 travel restrictions or quarantine. Yes No Identify your employer and explain why you could not get to work: 6. I could not work because a health care professional told me to quarantine. Yes No Provide dates, identify the health care professional, and explain why you were told to quarantine: 7. I was supposed to start work but could not due to COVID-19. Yes No Explain where and when you were supposed to start work and why you could not start the job: 8. I became the main breadwinner for my household because the previous breadwinner died from COVID-19. Yes No Provide date(s), former breadwinner’s name and relationship to you: 9. I had to quit my job as a direct result of COVID-19. Yes No Identify your employer and explain why you had to quit: 10. My workplace closed due to COVID-19. Yes No Identify your employer and provide dates: 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 Explain how your customary work activities were affected by COVID-19: 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 Identify the employer and provide details: 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 Identify the employer and provide details: 14. I was laid off, or my hours were reduced as a direct result of the COVID-19 health emergency. Yes No Identify the employer and provide details: 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 If you were not otherwise able and available to work, explain: 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 Explain what type of work you are seeking, what you have done to search for work, and how frequently. If you were not searching for work, explain why: I have not refused any offers of suitable work during a week I claimed PUA benefits. Yes No If you refused an offer of work during a week you claimed benefits, identify the empoyer and the date of the offer, and explain why you refused it. I was not able to telework (work from home) for full pay with my last employer. Yes No Identify employer and explain. I could not receive full paid leave with my last employer. Yes No Identify employer and explain. 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
