SOCIAL SECURITY NUMBER NAME WBA PROGRAM WEEK ENDING DATE
UNANSWERED QUESTIONS, OMITTED SIGNATURES, OR DAMAGED CARDS WILL DELAY YOUR BENEFIT PAYMENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN “X” IN THE BLOCK INDICATING EITHER
“YES” OR “NO” FOR THE CORRESPONDING WEEK.
YES NO
1. WERE YOU PHYSICALLY AND/OR MENTALLY ABLE TO WORK DURING THE WEEK CLAIMED?
2. OTHER THAN A HEALTH ISSUE, WERE YOU AVAILABLE FOR WORK DURING THE WEEK CLAIMED?
3. WERE YOU UNEMPLOYED, PARTIALLY UNEMPLOYED, OR UNABLE OR UNAVAILABLE TO WORK BECAUSE OF A COVID-19
RELATED REASON DURING THE WEEK CLAIMED? IF YES, INDICATE THE COVID-19 RELATED REASON BELOW. EARNINGS
4. DID YOU PERFORM WORK DURING THE WEEK CLAIMED? IF YES, INDICATE THE GROSS AMOUNT OF EARNINGS BEFORE ANY
DEDUCTIONS IN THE BOX TO THE RIGHT AND COMPLETE THE SECTION BELOW.
500
5. DID YOU BEGIN RECEIVING A SEVERANCE OR DID THE AMOUNT PREVIOUSLY REPORTED CHANGE? IF YES, INDICATE THE
GROSS AMOUNT IN THE BOX TO THE RIGHT.
6. DID YOU BEGIN RECEIVING A PENSION OR DID THE AMOUNT PREVIOUSLY REPORTED CHANGE? IF YES, INDICATE THE GROSS
AMOUNT IN THE BOX TO THE RIGHT.
7. DID YOU BEGIN SCHOOL/TRAINING OR WAS THERE A CHANGE IN YOUR CLASS SCHEDULE DURING THE WEEK CLAIMED?
8. DID YOU REFUSE WORK, QUIT A JOB, OR YOU WERE DISCHARGED FROM A JOB DURING THE WEEK CLAIMED?
9. DID YOU RETURN TO FULL-TIME WORK? IF YES, COMPLETE THE SECTION BELOW.
IF YOU ANSWERED “YES” TO QUESTION #3, PLEASE INDICATE THE COVID-19 RELATED REASON FOR WHY YOU WERE UNEMPLOYED, PARTIALLY UNEMPLOYED OR UNABLE OR UNAVAILABLE TO
WORK:
☐ My place of employment is closed as a direct result of the COVID-19 public health emergency.
☐ I am unable to reach my place of employment because of a quarantine imposed as a direct result of the COVID-19 public health emergency.
☐ I am unable to reach my place of employment because I have been advised by a health care provider to self-quarantine due to concerns related to COVID-19.
☐ I have been diagnosed with COVID-19 or am experiencing symptoms of COVID-19 and am seeking a medical diagnosis.
☐ A member of my household has been diagnosed with COVID-19.
☐ I am providing care for a family member or a member of my household who has been diagnosed with COVID-19.
☐ A child or other person in my household for which I am the primary caregiver is unable to attend school or another facility that is closed as a direct result of the COVID-19 public health emergency and such
school or facility care is required for me to work.
☐ I have become the breadwinner or major support for a household because the head of the household has died as a direct result of COVID-19.
☐ I was scheduled to commence employment and do not have a job or am unable to reach my job as a direct result of the COVID-19 public health emergency.
☐ I quit my job as a direct result of COVID-19.
IF YOU ANSWERED “YES” TO QUESTION #4 OR #9, PLEASE LIST THE DATE(S) OF YOUR EMPLOYMENT AND THE NAME AND ADDRESS OF YOUR EMPLOYER.
DATE(S) OF EMPLOYMENT: NAME AND ADDRESS OF EMPLOYER:
CERTIFICATION: I certify that the information I have provided is true, accurate, and complete to the best of my knowledge. I understand that making an intentional misrepresentation is fraud and is under
penalty of perjury. I also understand that I may be subject to criminal prosecution if found to have committed fraud.
SIGNATURE: DATE: ____________
