Form Ub-106-T - Continued Claim
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1
2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
UB-106-T (4-17)
Workforce Administration • Unemployment Insurance Program
CONTINUED CLAIM
CLAIMANT’S NAME
(Last, First, M.I.)
SOC. SEC. NO.
WEEK ENDING DATE
A. To be completed by the claimant for the Week Ending Date shown above.
Yes
No
1. Did you work or earn any money?
a. If yes, enter gross earnings: $
b. Employer Name:
c. Employer Address:
d. Are you still working?
e. If no, reason for separation:
2. Did you apply for or receive any training related assistance (other than tuition, cost of books or training costs) ?
a. If yes, give amount: $
b. Give source:
3. Did you miss any scheduled training?(Give dates and reason for absence)
4. Did your address or phone number change during this training week? If yes, enter your new address
and phone number.
CLAIMANT CERTIFICATION: I am claiming benefits 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 Training Facility for the Week Ending Date shown above.
Yes
No
1. Was the claimant enrolled in training?
a. If no, please explain:
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 answers
are correct and complete. Furthermore, the entry of item B.2. is based on established facility standards and procedures.
FACILITY NAME
PHONE NO.
AUTHORIZED SIGNATURE
DATE
PAYMENT UNIT AUTHORIZATION:
DEPUTY SIGNATURE
DATE
See reverse for EOE/ADA/LEP/GINA disclosure
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