Form Ucb/dua-11 Affirmation Of Self-Employment printable pdf download

Form Ucb/dua-11 Affirmation Of Self-Employment

DEPARTMENT OF ECONOMIC OPPORTUNITY

DISASTER UNEMPLOYMENT ASSISTANCE

AFFIRMATION OF SELF-EMPLOYMENT

COUNTY OF __________________

I, _________________________ SS# _____________________, hereby personally affirm that I was engaged in SELF-

EMPLOYMENT activities in the county stated above on _________________________.

To support my claim for SELF-EMPLOYMENT I offer the following statement:

The ending date of the tax year I file for is __________________. The total net earnings for the most recent tax year were

$_____________. My earnings during that tax year were:

_______QTR

______QTR

_____QTR

_______WKS

______WKS

_____WKS

_______EARNINGS

___________EARNINGS

__________EARNINGS __________EARNINGS

There were ______other individuals in my group whose earnings were reported under my Social Security number and who

are also filing for DUA benefits. The net earnings should be allocated as follows:

FULL NAME____________________________ SS#___________________ AGE_____ PERCENT______

RELATIONSHIP______________________

_______QTR

_____QTR

_______WKS

_____WKS

_______EARNINGS

__________EARNINGS __________EARNINGS __________EARNINGS

FULL NAME___________________________ SS#____________________ AGE_____ PERCENT______

RELATIONSHIP______________________

_______QTR

_____QTR

_______WKS

_____WKS

_______EARNINGS

__________EARNINGS __________EARNINGS __________EARNINGS

List additional group members to be included on the reverse side of this form.

I further state that I understand that the Florida Reemployment Assistance Law/Disaster Unemployment Assistance and the

Stafford Act provides penalties for knowingly making false statements for the purpose of obtaining RA/DUA benefits. I,

therefore, declare that the statement I have made in connection with this claim is true and correct to the best of my knowledge

and belief.

________________________________ _________ _______________________________

Claimant's Signature

Date

Department Representative

Note: You must provide documentation of employment and earnings within 21 calendar days from the date you file your claim. Failure to do so can result in

a reduction of your DUA weekly benefit amount and an overpayment or disqualification from the receipt of DUA benefits. However, documentation submitted

with a request for reconsideration anytime during the twenty six week disaster assistance period may be accepted.

UCB/DUA-11 (3/12)

1 of 2

Item 21