Pandemic Unemployment Assistance Statement of Employment and Wages

Job Service North Dakota
Unemployment Insurance/Benefits Area
SFN 61802

- Pandemic Number
- Job Service North Dakota
  701-328-1152
  TTY 1-800-366-6888
- Claimant First Name *
  Maximum of 12 characters allowed. Currently Entered: 0 characters.
- Middle Initial
  Maximum of 1 characters allowed. Currently Entered: 0 characters.
- Claimant Last Name *
  Maximum of 30 characters allowed. Currently Entered: 0 characters.
- Social Security Number *
  Must be 9 characters. Currently Entered: 0 characters.
- Please enter Social Security Number again to verify accuracy.
- Verify Social Security Number *
  Must be 9 characters. Currently Entered: 0 characters.
*In compliance with the Privacy Act of 1974, a Social Security Number is mandatory on this form pursuant to 20 CFR 666.150 and/or North Dakota CenturyCode 52-02-02. This number is used by Job Service North Dakota for identification, federal and state tax, program eligibility purposes and program performance accountability.
A. APPLICANT EMPLOYMENT

In order to compute the amount of my weekly entitlement to PANDEMIC UNEMPLOYMENT ASSISTANCE, I certify I had the following employment, self-employment, and earnings during calendar year 2019.
Name of Employer (or Self-Employment) *
- Address *
  Maximum of 30 characters allowed. Currently Entered: 0 characters.
- City *
  Maximum of 20 characters allowed. Currently Entered: 0 characters.
- State *
- ZIP Code *
  Must be 5 digits. Currently Entered: 0 digits.
- Employment Start Date *
- Employment End Date *
- 2019 Total Gross/Net * Earnings *
- Weekly Wage *
- Hours Worked Weekly *
  Maximum of 2 digits allowed. Currently Entered: 0 digits.
* Report NET earnings if self-employed and GROSS earnings if a wage earner for calendar year 2019.
Check Here to Add Another Employer
Employer Two
Name of Employer (or Self-Employment) 2
- Address
  Maximum of 30 characters allowed. Currently Entered: 0 characters.
- City
  Maximum of 20 characters allowed. Currently Entered: 0 characters.
- State
- ZIP Code
  Must be 5 digits. Currently Entered: 0 digits.
- Employment Start Date
- Employment End Date
- 2019 Total Gross/Net * Earnings
- Weekly Wage
- Hours Worked Weekly
  Maximum of 2 digits allowed. Currently Entered: 0 digits.
* Report NET earnings if self-employed and GROSS earnings if a wage earner for calendar year 2019.
Check Here to Add Another Employer
Employer Three
Name of Employer (or Self-Employment) 3
- Address
  Maximum of 30 characters allowed. Currently Entered: 0 characters.
- City
  Maximum of 20 characters allowed. Currently Entered: 0 characters.
- State
- ZIP Code
  Must be 5 digits. Currently Entered: 0 digits.
- Employment Start Date
- Employment End Date
- 2019 Total Gross/Net * Earnings
- Weekly Wage
- Hours Worked Weekly
  Maximum of 2 digits allowed. Currently Entered: 0 digits.
* Report NET earnings if self-employed and GROSS earnings if a wage earner for calendar year 2019.
Check Here to Add Another Employer
Employer Four
Name of Employer (or Self-Employment) 4
- Address
  Maximum of 30 characters allowed. Currently Entered: 0 characters.
- City
  Maximum of 20 characters allowed. Currently Entered: 0 characters.
- State
- ZIP Code
  Must be 5 digits. Currently Entered: 0 digits.
- Employment Start Date
- Employment End Date
- 2019 Total Gross/Net * Earnings
- Weekly Wage
- Hours Worked Weekly
  Maximum of 2 digits allowed. Currently Entered: 0 digits.
* Report NET earnings if self-employed and GROSS earnings if a wage earner for calendar year 2019.
Check Here to Add Another Employer
Employer Five
Name of Employer (or Self-Employment) 5
- Address
  Maximum of 30 characters allowed. Currently Entered: 0 characters.
- City
  Maximum of 20 characters allowed. Currently Entered: 0 characters.
- State
- ZIP Code
  Must be 5 digits. Currently Entered: 0 digits.
- Employment Start Date
- Employment End Date
- 2019 Total Gross/Net * Earnings
- Weekly Wage
- Weekly Hours
  Maximum of 2 digits allowed. Currently Entered: 0 digits.
* Report NET earnings if self-employed and GROSS earnings if a wage earner for calendar year 2019.
Check Here to Add Another Employer
Employer Six
Name of Employer (or Self-Employment) 6
- Address
  Maximum of 30 characters allowed. Currently Entered: 0 characters.
- City
  Maximum of 20 characters allowed. Currently Entered: 0 characters.
- State
- ZIP Code
  Must be 5 digits. Currently Entered: 0 digits.
- Employment Start Date
- Employment End Date
- 2019 Total Gross/Net * Earnings
- Weekly Wage
- Hours Worked Weekly
  Maximum of 2 digits allowed. Currently Entered: 0 digits.
* Report NET earnings if self-employed and GROSS earnings if a wage earner for calendar year 2019.
IMPORTANT: You must furnish documentation to substantiate the employment or self-employment upon which this application is filed to support that you were employed or self-employed on the date the COVID-19 pandemic occurred. You must also submit a copy of your 2019 federal income tax forms to establish your monetary entitlement. Failure to provide this documentation within 21 days of the date you filed your claim will result in denial of PUA benefits and you will be required to repay any PUA benefits paid to date.
Attach Federal Income Tax Forms
* Accepted file types include pdf, tif, tiff, jpg, jpeg
* Max of 5 files
* Each file must not exceed 10MB in size

Attach Files Attach Files
APPLICANT CERTIFICATION

I certify that the information I have given on this form is correct and that I have supplied the information in order to obtain DISASTER UNEMPLOYMENT ASSISTANCE. I know that federal funds are provided and that penalties are prescribed by law for willful misrepresentation or concealment of material facts in order to obtain assistance payments which I am not entitled to receive under the ACT.
- Signature of Claimant *
- Date *
Job Service North Dakota is an equal opportunity employer/program provider.
Auxilary aids and services are available upon requst to individuals with disabilities.

Pandemic Unemployment Assistance Statement of Employment and Wages

Pandemic Unemployment Assistance Statement of Employment and Wages

Job Service North Dakota 701-328-1152 TTY 1-800-366-6888

Please enter Social Security Number again to verify accuracy.

A. APPLICANT EMPLOYMENT

* Report NET earnings if self-employed and GROSS earnings if a wage earner for calendar year 2019.

Employer Two

* Report NET earnings if self-employed and GROSS earnings if a wage earner for calendar year 2019.

Employer Three

* Report NET earnings if self-employed and GROSS earnings if a wage earner for calendar year 2019.

Employer Four

* Report NET earnings if self-employed and GROSS earnings if a wage earner for calendar year 2019.

Employer Five

* Report NET earnings if self-employed and GROSS earnings if a wage earner for calendar year 2019.

Employer Six

* Report NET earnings if self-employed and GROSS earnings if a wage earner for calendar year 2019.

APPLICANT CERTIFICATION

Job Service North Dakota is an equal opportunity employer/program provider. Auxilary aids and services are available upon requst to individuals with disabilities.

Job Service North Dakota
701-328-1152
TTY 1-800-366-6888

Job Service North Dakota is an equal opportunity employer/program provider.
Auxilary aids and services are available upon requst to individuals with disabilities.