Form Ub-106-T - Completion Instructions For Approved Training Continued Claim Page 2
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1
2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Workforce Administration•
Unemployment
Insurance Program
CONTINUED CLAIM
- - - - . .
CLAIMANT'S NAM
E
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M
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__________________________ _
SOC
SEC.
NO
WEEK
ENDING
DATE
_ _ _ _ _ _ _ _ _ _ _ _
, . . . - -
___.
A.
To be completed by the claimant for the Week Ending Date shown
above.
Yes
No
D
D
1.
Did you
wo
rk
or
earn any money?
a.
If yes
1
enter gross
earnings:
$
b.
Employer Name:
C
Employer
Address:
D
D
d.
Are you still
working?
e.
If
no,
reason for separation
:
D
D
2.
Did
you
apply
for
or receive
any trainirg related assistanoe
(other
than
tuition,
cost of bcoks or training
costs)?
a
If
yes,
gr,e
amount:
$
b
Give
source·
D
D
3.
Did
you miss
any scheduled
tra
ining?(Give
dates
and
reason for absenoe)
D
D
4.
Did
your
address or phone number
change dunng thts tra,ning week?
If
yes,
enter
your
new
address
and phone number
CLAIMANT CERTIFICATION
:
I
am claiming benefrts under the Approved Training
Provisions
of the Employment Security
Law of
Arizona
for the calendar
week
ending as shown
above.
I
certify
that the
information
given
is
correct.
I
understand
that the
law
provides penalties for false statements made in connection with this
claim
CLAIMANT
SIGNATURE
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
DATE
_ _ _ _ _ _ _ _ _
/
B.
To be completed by the Tram mg Fac1l1ty for the Week Ending Date shown
above.
Yes
No
D
D
was the claimant enrolled
in
training?
a.
If no
,
please explain
:
0
0
2.
Was
the claimant satisfactorily pursuing the training
course?
a.
If
no,
please
explain:
TRAINING FACILITY CERTIFICATION:
To
the
best of
my
knowledge and
according
to
our
records,
the above
answe
rs
are correct and
complete.
Furthermore,
the entry of item
B.2.
is
based on
established faci
lity
standards and
procedures.
FACILITY
NAM
E
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
PHONE
NO.
_ _ _ _ _ _ _ _
AUTHORIZED SIGNATURE
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
DATE
_ _ _ _ _ _ _ _
PAYMENT UNIT AUTHORIZATION
:
DEPUTY
SIGNATURE
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
DATE
_ _ _ _ _ _ _ _
ANSWER ALL QUESTIONS BELOW
Enter the week-ending
Print your name here
date you are filing for.
Remember, this must
Print your Social Security
be a Saturday date!!!
Number here
Enter the date you are
submitting your claim.
Remember, this must
be at least one day after
Sign your name here
the week-ending date!!!
Training facility will
complete and sign this
section.
Certification by the Training Facility: The authorized Training Facility Representative shall sign and date the weekly
claim form. Claim forms signed by someone other than the Authorized Training Facility Representative cannot be ac-
cepted for payment. Incomplete or incorrect forms will be returned for correction and will cause a delay in the payment
of the claimant’s benefits. Claimants who have completed the Approved Training Program and wish to continue to file for
Unemployment Insurance should file through the Internet at , or by telephone at 602-364-2722 (Phoenix),
520-791-2722 (Tucson) or 1-877-600-2722 (outside of Maricopa and Pima counties).
Mail the completed form to:
Approved Training Unit, Mail Drop 589C
P.O. Box 6666
Phoenix, AZ 85005
Or fax to: (602) 495-3135
Do not mail claims in the regular Unemployment Benefits envelope
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in
admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability,
genetics and retaliation. To request this document in alternative format or for further information about this policy, contact
your local office manager; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
Ayuda gratuita con traducciones relacionadas con los servicios del DES esta disponible a solicitud del cliente.
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