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UB-106-A-FF (7-13)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Unemployment Insurance Administration

Weekly Claim for Unemployment Insurance (UI) Benefits

NAME

SOCIAL SECURITY NUMBER

WEEK ENDING DATE

     

     

     

You may file your weekly claim for UI Benefits on the Internet at . You can also return this form that will be mailed to you each week. Filing on the Internet may result in faster payment of benefits because the mail delivery and processing time would be eliminated.

Answer these questions for the week that ended on the date above.

  1. Were you able to work and available for work each regular workday?

YES



NO



  1. Did you look for work? (You MUST report your work search below)

YES



NO



The law requires that for you to be considered as actively seeking work you must engage in a systematic and sustained effort to obtain work during at least four days of the week and you must make at least three work search contacts during the week.

Complete the following information for the week ending date listed above: (Four (4) entries are required)

Date

Name of Employer/Company/Union and Address (City, State and Zip) or (Web URL, email address)

Name of person contacted

Method (In person, Internet, mail)

Type of Work Sought

Results (Application Filed, Interview, etc.)

     

     

     



     

     

     

     

     



     

     

     

     

     



     

     

     

     

     



     

     

  1. Did you refuse any job offer or referral to work?

YES



NO



  1. Did you work or earn any money?

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 4a and 4b)

4a. What were your gross earnings before deductions

$

     

4b. Are you still working? (If NO, check reason for separation below)

YES



NO



 Lack of work

 Quit

 Fired or Discharged

 Labor Dispute

  1. Have you returned to full-time work which will not require you to file any further weekly claims at this time?

YES



NO



Failure to disclose that you have returned to work may result in prosecution and payment of restitution.

  1. Do you decline to file for the week because you did not meet the work search requirements in
    #2 above?

YES



NO



If you did not look for work or meet the required contacts, you will be disqualified until you are reemployed and earn eight times your weekly benefit amount. You have the option to decline to file for the week. If you decline to file, you will not receive benefits for the week. (If YES, you must answer 6a.)

6a. Would you like to receive a paper weekly claim by mail for the next benefit week ending date?

YES



NO



I am claiming benefits for the calendar week that ended on Saturday midnight, as shown above. I certify that I was registered for work and unemployed. I further certify that the above statements are correct, to the best of my knowledge and that I have reported all changes in writing. I understand that the law provides penalties for false statements in connection with this claim and I certify that all the answers I have given are true.

Claimant’s Signature

     

Date

     

When completed, fax to:

602-364-1210 or 602-364-1211 (Phoenix)
520-770-3357 or 520-770-3358 (Tucson)

You may also mail to:

Arizona Department of Economic Security

P.O. Box 29225

Phoenix AZ 85038-9225

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. Auxiliary aids and services are available upon request to individuals with disabilities. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact your local office manager; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. • Disponible en español en línea o en la oficina local.



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