Form Ucb/dua - 61 Dua Weekly Claim Certification

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DUA WEEKLY CLAIM CERTIFICATION
FOR OFFICE USE ONLY – DO NOT WRITE IN THIS SECTION
SSN
_______-______-________
BP 60 _________________
FEMA ______________________
ISSUE _________________
PROGRAM ID ________________
CLAIMSTAKER
INITIALS
SUPPRESS
__________
SUBSEQUENT__________
IMPORTANT – CAREFULLY COMPLETE THIS FORM AS INSTRUCTED
Claimant’s Name; ________________________________
SS #: _________-_______-_________
MARK THE CORRECT ANSWER
Week Ending
Week Ending
1. I claim Disaster Unemployment Assistance for these weeks:
_____-_____-_____
_____-_____-_____
2.
During each of these weeks:
(A) Were you able and available for work?
Yes ___ No ___
Yes ___ No ___
(B) Did you contact your last employer to determine if work was
available?
Yes ___ No ___
Yes ___ No ___
(C) Did you apply for or receive, or would be eligible to receive if applied for:
(1) Any RI benefits under any other state or federal law?
Yes ___ No ___
Yes ___ No ___
(2) Any amount of loss of wages due to illness or disability? Yes ___ No ___
Yes ___ No ___
(3) Any type of private income protection insurance?
Yes ___ No ___
Yes ___ No ____
(4) Any amount as a supplemental unemployment benefit? Yes ___ No ___
Yes ___ No ____
(5) Any amount of retirement, pension, or annuity income? Yes ___ No ___
Yes ___ No ____
(D) Did you refuse any offer of work?
Yes ___ No ___
Yes ___ No ____
(E) Did you work for another or engage in any self-employment? Yes ___ No ____
Yes ___ No ____
IF YES: Enter gross earnings whether received or not.
$ ____________._____
$ ___________.____
(If self-employment, enter gross earnings when received)
3.
If your mailing address has changed since filing your last certification, mark here and enter new address: ___________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
4.
CERTIFICATION: I certify that I have supplied this information voluntarily in order to obtain Disaster Unemployment
Assistance. I claim assistance for this period with full knowledge 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
for which I am not entitled under the Act. I have been furnished a statement required under the Privacy Act of 1974 for
use in the Disaster Unemployment Assistance Program. I certify my statements and answers are true and correct.
Claimant Signature __________________________ Date__________
Phone No (________) __________-__________
UCB/DUA – 61 (Rev 03-12)
Item 10

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