Form Ub-092-A Forff - Confidential Financial Statement
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3ARIZONA DEPARTMENT OF ECONOMIC SECURITY
UB-092-A FORFF (4-17) – Page 1
Workforce Administration • Unemployment Insurance Program
Benefit Payment Control Unit - Mail Drop 5893
PO Box 6123, Phoenix, AZ 85005
Telephone: (602) 364-4300 Fax: (602) 364-1210, (520) 770-3357, (928) 726-0646
CONFIDENTIAL FINANCIAL STATEMENT
CLAIMANT INFORMATION (Please complete both pages of this document):
Name
Date of Birth
Social Security Number
Drivers License Number
(Required to verify information)
Partner / Spouse’s Name
Date of Birth
Social Security Number
Drivers License Number
(Required to verify information)
Residential Address (No., Street, Apt., P.O. Box)
City
State
ZIP Code
Mailing Address (No., Street, Apt., P.O. Box)
(If different than above)
City
State
ZIP Code
Home Phone Number
Cell Number
Work Phone Number
I request a waiver of recoupment of the overpayment of Unemployment Insurance Benefits because:
LIST ALL OTHER HOUSEHOLD MEMBERS INCLUDING RELATIONSHIPS AND DATE OF BIRTH:
NAME
RELATIONSHIP
DATE OF BIRTH
LIST ALL SOURCES OF EARNED INCOME (Wages, self-employment, etc.):
Name of Person Working
Gross Amount Monthly $
Name of Employer (Company)
Employer Address (No., Street, P.O. Box)
City
State
ZIP Code
Phone Number
Name of Person Working
Gross Amount Monthly $
Name of Employer (Company)
Employer Address (No., Street, P.O. Box)
City
State
ZIP Code
Phone Number
If Unemployed, specify wages earned when you were working: $
per
LIST ALL SOURCES OF UNEARNED INCOME (Social Security/SSI benefits, Railroad retirement, Child support,
Alimony, Veterans benefits, Public assistance, HUD, BIA, gifts, etc.):
NAME OF PERSON RECEIVING BENEFITS:
TYPE OF INCOME RECEIVED
MONTHLY AMOUNT RECEIVED
$
$
$
See page 3 for EOE/ADA/LEP/GINA disclosures
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