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Pandemic Unemployment Weekly Certification Assistance Form
Do you wish to continue to file this Pandemic Unemployment claim?
Yes. I wish to continue to file this claim
No. I do not want to continue this claim. Please close my file.
Not sure. I would like a consultation.
How did COVID19 cause your Unemployment?
Choose an option
You have been diagnosed with COVID-19 or are experiencing symptoms of COVID-19 and are seeking a med
A member of your household has been diagnosed with COVID-19.
You are providing care for a family member or a member of your household who has been diagnosed with
A child or other person in your household for which you have primary caregiving responsibility is un
You stopped working because you are unable to reach your place of work after a public official's req
You are unable to reach your place of employment because you have been advised by a health care prov
You were scheduled to commence employment and do not have a job or are unable to reach the job as a
You have become the breadwinner or major support for a household because the head of the household h
You have a reduction in gig work due to COVID-19. Gig work includes: Uber, Lyft, Musicians, Instacar
You worked for a church or non profit who is closed due to COVID-19.
You were to start working but was unable to due to the closure of the business caused by COVID-19.
You were laid off due to a lack of work after a business closure caused by COVID-19.
Your employer reduced your hours due to COVID-19.
You are self employed. Your services have stopped due to the governor's order .
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Other than the impact of COVID19, where you available and able to accept fulltime employment?
Yes
No
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Did you or will you recieve any "Other Income" of the following?
Workers' Compensation
Private Income Protection
Supplemental Unemployment Benefit
Pension and Allowance
None of the above
Did you start school or training?
Choose an option
Yes
No
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Are you still Unemployed?
Choose an option
Yes
No
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Where you offered a job and REFUSED to take it?
Choose an option
Yes
No
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Did you work and earn money during this week?
Choose an option
Yes
No
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Acknowledgement AcknowledgementAcknowledgement Required Field I acknowledge that I understand that making the certification is under penalty of perjury and intentional misrepresentation in self-certifying that I may fall in one or more of these categories is fraud.
I have read and understand the information regarding potential fraud penalties and acknowledge that the information on this page is true and accurate and wish to continue to file my weekly certification.
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Thank you for submitting your certification assistance form.
