Form Ub-106-A-Ff - Weekly Claim For Unemployment Insurance (Ui) Benefits
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
UB-106-A -FF (4-17)
Unemployment Insurance Program
Weekly Claim for Unemployment Insurance (UI) Benefits
NAME
SOCIAL SECURITY NUMBER
WEEK ENDING DATE
You may file your weekly claim for UI Benefits on the Internet at . You can also return this form that will be
mailed to you each week. Filing on the Internet may result in faster payment of benefits because the mail delivery and
processing time would be eliminated.
Answer these questions for the week that ended on the date above.
1. Were you able to work and available for work each regular workday?
YES
NO
2. Did you look for work? (You MUST report your work search below)
YES
NO
To be considered as actively seeking work you must (1) engage in a systematic and sustained effort to obtain work on at
least four days of the week and (2) make at least one job contact per day on four different days of the week.
For the week ending on the date shown above, check the days you looked for work and list one job contact per day on
four different days of the week. Four (4) contacts are required
Sun
Mon
Tue
Wed
Thur
Fri
Sat
Name of Employer/Company/Union
Name of person
Method (In person,
Type of work
Results (Application
Date
and Address (City, State and Zip Code)
contacted
Internet, mail)
sought
Filed, Interview, etc.)
or (Web URL, email address)
3. Did you refuse any job offer or referral to work?
YES
NO
4. Did you work or earn any money, including part-time work?
YES
NO
The department regularly matches hiring information with employer records. Failure to report
earnings may result in prosecution and payment of restitution. (If YES, you must answer 4a. and 4b.)
4a. What were your gross earnings before deductions?
$
4b. Are you still working? (If NO, check reason for separation, and answer 4b1 and 4b2 below.)
YES
NO
Lack of work
Quit
Fired or Discharged
Labor Dispute
4b1. Name of company you separated from:
4b2. What was your last day of work?
5. Have you returned to full-time work which will not require you to file any further weekly claims at this time?
Failure to disclose that you have returned to work may result in prosecution and payment of restitution.
YES
NO
6. Do you decline to file for the week because you did not meet the work search requirements in #2 above?
YES
NO
I am claiming benefits for the calendar week that ended on Saturday midnight, as shown above. I certify to the following: I
was registered for work and unemployed. The above statements are true and correct to the best of my knowledge. I have
reported all changes in writing. I understand that the law provides penalties for false statements made in connection with
this claim and if any issues arise from my answers above, the department will contact me.
CLAIMANT’S SIGNATURE
DATE
When completed, fax to:
You may also mail to: Arizona Department of Economic Security
602-364-1210 or 602-364-1211 (Phoenix)
P.O. Box 29225
Phoenix AZ 85038-9225
520-770-3357 or 520-770-3358 (Tucson)
See page 2 (Instructions) for EOE/ADA/LEP/GINA disclosures.
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