UIB-1245A-FORFF (5-20) ARIZONA DEPARTMENT OF ECONOMIC SECURITY Page 1 of 2
Unemployment Insurance Program
Weekly Claim for Pandemic Unemployment Assistance
(PUA) Benefits
Name:
Social Security Number:
You may file your weekly claim for PUA Benefits on the Internet at AZUI.COM. You can also return this form by fax or
mail with the information provided below. Filing on the Internet may result in faster payment of benefits because the mail
delivery and processing time would be eliminated.
To qualify for PUA, you must self-certify that you are otherwise able to work and available for work, except that
you are unemployed, partially unemployed, unable to work or unavailable for work due to at least one of the
following categories listed in the CARES Act. I hereby self-certify that my unemployment is due to the following
circumstance(s):
I have been diagnosed with COVID-19 or I am
experiencing symptoms of COVID-19 and I am
seeking a medical diagnosis.
Guidance for answering the following questions is located on page 2 of this form.
1. Except for the COVID-19 reason you selected above, were you able to work Yes No
each regular workday?
2. Except for the COVID-19 reason you selected above, were you Yes No
available for work each regular workday?
3. Did you look for work? Yes No
4. Did you refuse any job offer or referral to work? Yes No
5. 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 5a. and 5b.)
5a. What were your gross earnings before deductions? $
5b. Are you still working? (If NO, check reason for separation, and answer 5b1 and 5b2 below.) Yes No
5b1. Name of company you separated from:
5b2. What was your last day of work (MM/DD/YYYY)?
6. 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
7. Did you begin attending any type of school or training this week? Yes No
Please complete both pages of this weekly certification.
See page 2 (Instructions) for EOE/ADA disclosures.
UIB-1245A-FORFF (5-20) ARIZONA DEPARTMENT OF ECONOMIC SECURITY Page 2 of 2
Unemployment Insurance Program
I am claiming benefits for the calendar week that ended on Saturday midnight, as shown above. 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. I understand that the
CARES Act self-certification made on this form is under penalty of perjury and that any intentional misrepresentation in self certifying that
I fall into the COVID-19 category listed above is fraud. I understand that if I am found to have committed fraud I may be subject to criminal
prosecution.
Claimant’s Signature Date
Instructions for Completing Weekly Claim for PUA Benefits
You must file a weekly claim each week. A determination will not be made until you file a weekly claim. All weekly claims are
for a calendar week which starts at 12:01 a.m. Sunday and ends at 12:00 midnight on the following Saturday. Weekly claims
cannot be filed until after the calendar week has ended.
Below is a brief explanation for each of the questions you will be required to answer each week.
1. Except for the COVID-19 reason you selected above, were you able to work each regular workday?
Able to work - You are able to work if you have no mental or physical condition that prevents you from working or
accepting work.
2. Except for the COVID-19 reason you selected above, were you available for work each regular workday?
Available for work - You are available for work if you do not have any restrictions that would prevent you from looking for
or accepting full-time work when offered.
3. Did you look for work?
DES temporarily suspended the “actively seeking work” requirement due to COVID-19. Your answer to question 3
will not be used to determine your eligibility at this time.
4. Did you refuse any job offer or referral to work?
Refusing a job offer or referral to work – you turned down work that was offered to you or you did not report to an
employer that you were referred to from the Employment Service office.
5. Did you work or earn any money, including part-time work?
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 5a. and 5b.)
5a. What were your gross earnings before deductions?
If you performed any work or earned any money you must report it on your weekly claim. You must report the total
amount earned before deductions. Wages must be reported the week in which the work is performed even if you
have not been paid yet.
5b. Are you still working?
NO – Lack of work or a Reduction in force – laid off, no more work was available
Quit – Voluntarily left employment
Fired, discharged or Let go – Misconduct
Labor Dispute – A dispute or disagreement which results in a strike or lockout at the place of employment.
The department will confirm that a labor dispute exists.
6. 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 - that you are working and earning an income in excess of your weekly benefit amount and do not have to file a weekly
claim.
NO - you are still unemployed and wish to continue filing a weekly claim.
7. Did you begin attending any type of school or training this week?
Answer “Yes “ if you started a new term or new class during this week. This includes attending school as a full time
student and a part time student.
When completed, fax to: You may also mail to: Arizona Department of Economic Security
(888) 417-3638 (Toll-Free) ATTN: PUA Processing MD 5895
(602) 362-5389 (Phoenix) P.O. Box 29225
Phoenix AZ 85038-9225
Equal Opportunity Employer / Program • 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 • Disponible en español en línea o en la oficina local
