Form Ub-113 - Combined-Wage Claim Withdrawal
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1ARIZONA DEPARTMENT OF ECONOMIC SECURITY
UB-113 (4-17)
Workforce Administration • Unemployment Insurance Program
COMBINED-WAGE CLAIM WITHDRAWAL
CLAIMANT INFORMATION
NAME
SOCIAL SECURITY NUMBER
(Please print or type)
ADDRESS (No., Street)
CITY
STATE
ZIP CODE
PHONE NUMBER
I want to withdraw my combined-wage claim against Arizona and intend to file an individual claim against the State of
I have not received any unemployment insurance benefits as a result of my Arizona combined-wage claim.
I have received unemployment insurance benefits from my Arizona combined-wage claim. To repay the overpayment
created by withdrawing my claim,
I am immediately repaying the State of Arizona (attach check or money order) in the amount of
$
I authorized the State of
to deduct an amount sufficient to repay this
overpayment of $
and to forward these benefits to the State of Arizona.
CLAIMANT’S SIGNATURE
DATE
Subscribed and sworn before me this
day of
20
DEPUTY’S SIGNATURE
(Authorized representative to administer oaths and affirmations pursuant to Arizona Revised Statutes § 23-675)
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. The Department must make a
reasonable accommodation to allow a person with a disability to take part in a program, service, or activity. Auxiliary aids and services
are available upon request to individuals with disabilities. To request this document in alternative format or for further information about
this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
• Disponible en español en línea o en la oficina local.
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