Form Ub-106-T - Completion Instructions For Approved Training Continued Claim printable pdf download

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

UB-106-T -i (8-17)

Unemployment Insurance

COMPLETION INSTRUCTION FOR APPROVED TRAINING

CONTINUED CLAIM, UB-106-T

All claims for Unemployment Insurance are for the calendar weeks beginning SUNDAY and ending at MIDNIGHT

on the following SATURDAY. Do not complete, sign or mail the form until the SUNDAY or MONDAY following the

week for which you are claiming. Claims signed or mailed prior to midnight of the Saturday week ending

date will be returned to you and payment will be delayed. Please print and sign clearly in black ink.

Approved Training weekly continued claims are not accepted by telephone.

If, while participating in the Approved Training Program, you run out of forms or you need help, please call the

APPROVED TRAINING UNIT at 602-364-4119. If you are not within the Phoenix metropolitan area and the

call would be long-distance, phone the nearest ARIZONA@WORK Job Centers, and they will relay a message

to the APPROVED TRAINING UNIT to return your call.

PENALTIES: Any person who knowingly makes a false statement or representation believing it to be false or

who knowingly fails to disclose a material face in order to obtain or increase a benefit or other payment under

Chapter 4 of the Employment Security Law either for self or for another person, or under an employment secu-

rity law of another state, the federal government, or a foreign government, is guilty of a class six felony. Each

such statement or representation or failure to disclose a material fact shall constitute a separate offense.

SECTION A. COMPLETED BY THE CLAIMANT

Print your NAME, SOCIAL SECURITY NUMBER and WEEK ENDING DATE (SATURDAY) in the spaces indi-

cated at the top of the form.

Question 1:

Mark the “No” box if during the week claimed you did not work or perform services for which

you were paid. If you worked or were self-employed during the week, mark the “Yes” box and

complete part “a” (gross earnings), part “b” (name of employer), part “c” (address of employer),

and part “d” (if still working). If you are no longer working, complete part “e” (enter reason why

you are no longer employed).

Question 2:

Mark the “No” box if during the week claimed you did not receive payment or subsistence of

any kind of participating in training. Mark the “Yes” box if you received any allowances, bene-

fits, wages or other payments for participating in training (other than unemployment insurance

benefits received). If you mark the “Yes” box, complete part “a” showing the source and part “b”

showing the amount of the assistance payment received for the week claimed.

Question 3:

Mark the “Yes” or “No” box. If you missed training, you must include the scheduled dates you

missed, and the reason for your absence.

Question 4:

Mark the “Yes” box if your address has changed since you last submitted a weekly claim form,

and print the new address and your current phone number.

SECTION B. TO BE COMPLETED BY A REPRESENTATIVE OF THE TRAINING FACILITY

Question 1:

Mark the “Yes” or “No” box indicating whether or not the claimant was enrolled in training

during the week being claimed. If the “No” box is marked, please give a brief explanation. If

more space is required, use the reverse side of the weekly claim form.

Question 2:

Mark the “Yes” or “No” box indicating whether or not the claimant was “satisfactorily pursuing”

the training course. NOTE: IF, FOR ANY REASON THE CLAIM¬ANT WOULD NOT COM-

PLETE THE TRAINING PROGRAM AS ORIGINALLY SCHEDULED, HE/SHE SHOULD NOT

BE CONSIDERED AS “SATISFACTORILY PURSUING” THE COURSE.

Your training facility:

Take your continued claim form to:

Authorized Representative

See reverse for EOE/ADA/LEP/GINA disclosures

Form Ub-106-T - Completion Instructions For Approved Training Continued Claim

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