Form Ucb/dua-6 Affidavit Of Scheduled Employment
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1DEPARTMENT OF ECONOMIC OPPORTUNITY
DUA Claims
PO Drawer 5350
TALLAHASSEE, FLORIDA 32314-5350
AFFIDAVIT OF SCHEDULED EMPLOYMENT
Applicant Instructions:
Complete section A concerning employment which you were scheduled to begin but are now
unable to do so as a result of the disaster.
Then
take this form to the employer you
listed in section A and have the employer complete section B.
Return the completed form to
the address at the top of this page within 21 calendar days.
A.
APPLICANT CERTIFICATION
__________________________________________________________________________________________
NAME_____________________________________SS#______________________________________________
OCCUPATION____________________________LO#_________________________________________________
IN ORDER TO QUALIFY FOR DISASTER UNEMPLOYMENT ASSISTANCE, I CERTIFY THAT I HAD A
CONTRACT
TO BEGIN EMPLOYMENT WITH THE EMPLOYER INDICATED
BELOW BUT WAS NOT EMPLOYED DUE TO
THE
DISASTER.
NAME OF EMPLOYER__________________________________________________________________________
ADDRESS___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
DATE EMPLOYMENT WOULD HAVE BEGUN__________________________________________________________
I KNOW 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
TO WHICH I AM NOT ENTITLED TO RECEIVE UNDER THE ACT.
SIGNATURE__________________________________DATE___________________________________________
B.
EMPLOYER CERTIFICATION
__________________________________________________________________________________________
I CERTIFY THAT THE INDIVIDUAL NAMED ABOVE HAD A CONTRACT TO BEGIN EMPLOYMENT FOR ME ON
_______________________________________ AS A______________________________________________
(date)
(occupation)
AT THE WEEKLY/HOURLY RATE OF ______________ AND WORK ___________ HOURS PER DAY.
I FURTHER CERTIFY THIS CONTRACT WAS NOT FULFILLED DUE TO THE DISASTER.
EMPLOYER NAME ____________________________________________________________________________
ADDRESS___________________________________________________________________________________
_________________________________________________________________________________
PHONE # __________________________________________________________________________________
FEDERAL ID# ________________________ STATE R.A.# _________________________________________
I UNDERSTAND THAT FEDERAL FUNDS ARE PROVIDED AND THAT PENALTIES ARE PRESCRIBED BY LAW
FOR
WILLFUL MISREPRESENTATION OR CONCEALMENT OF MATERIAL FACTS IN ORDER TO
ASSIST OTHERS IN
OBTAINING ASSISTANCE PAYMENTS TO WHICH THEY ARE NOR ENTITLED TO RECEIVE UNDER THE ACT.
Signature_______________________________________ Title_____________________________________
NOTE:
Must be completed within 21 calendar days from the date you filed your claim.
Failure to do so can result
in a reduction of your DUA weekly benefit amount and an overpayment or you may be
disqualified from receiving
benefits.
However, documentation submitted with a request for reconsideration anytime during the twenty six week
disaster assistance period may be accepted.
Must also be completed for any minor (under age 18) not working at the
time of the disaster but scheduled to work.
UCB/DUA-6 (REV. 03/12)
Item 19
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