UI / DE 4581PUA

SAMPLE, this page for reference only.

Continued Claim - Pandemic Unemployment Assistance (PUA)

Answer each question in blue or black ink. See reverse on how to complete the answers correctly and avoid delays. Or submit your answers online at edd.ca.gov/UI_Online to get paid sooner. 1st Week 2nd Week
Begin
Ends		 Begin
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Yes No Yes No
Complete, sign, and mail this form on
1. Were you too sick or injured to work for reasons other than the COVID-19 pandemic?
  If yes, enter the number of days (1 through 7) you were unable to work.
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(1-7)
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(1-7)
2. Was there any reason (other than sickness, injury, or the COVID-19 pandemic) that you could not have accepted full-time work each workday?
3. Did you look for work or contact your last employer, or, if self-employed, did you attempt to resume self-employment?
← If marked ‘X’, you must complete Sec. A, Work-Search Record, on reverse.
4. Did you refuse any work?
5. Did you receive disability, private income insurance, or supplemental unemployment benefits?
6. Did you work or earn any money, WHETHER YOU WERE PAID OR NOT? Self-employed, report earnings during the week you receive the money.
(If yes, you MUST COMPLETE items a. and b. below.)
a. Enter earnings before deductions here (gross from self-employment). $
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 $
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b. Report employment or 'source' of earnings information below:
Date Last Worked Total Hours Worked Employer Name and Mailing Address - Include ZIP code Reason No Longer Working (or Write "Still Working")
1st Week        
2nd Week        
7. If you want federal income tax withheld for the week(s) shown above, mark this block.
8. If you had a change of mailing address or phone number, mark this block and complete Sec. B, New Mailing Address on reverse.
9. What reason(s) best describes how your unemployment, partial unemployment, or inability or unavailability to work for the weeks on this form was caused by the COVID-19 public health emergency? 1st Week 2nd Week
a) My place of employment is closed as a direct result of the COVID-19 public health emergency.
b) I quit my job as a direct result of COVID-19.
c) 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.
d) 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.
e) 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.
f) I am self-employed and experienced a significant reduction of services because of COVID-19.
g) I have been diagnosed with COVID-19 or I am experiencing symptoms of COVID-19 and am seeking a medical diagnosis.
h) A member of my household has been diagnosed with COVID-19.
i) I am providing care for a family member or a member of my household who has been diagnosed with COVID-19.
j) I was scheduled to commence employment and do not have a job or am unable to reach the job as a direct result of the COVID-19 public health emergency.
k) I have become the breadwinner or major support for my household because the head of the household has died as a direct result of COVID-19.
l) I was denied continued unemployment benefits because I refused to return to work or accept an offer of work at a worksite that, in either instance, is not in compliance with local, state, or national health and safety standards directly related to COVID-19. This includes, but is not limited to, those related to facial mask wearing, physical distancing measures, or the provision of personal protective equipment consistent with public health guidelines.
m) I provide services to an educational institution or educational service agency and am unemployed or partially unemployed because of volatility in the work schedule that is directly caused by the COVID-19 public health emergency. This includes, but is not limited to, changes in schedules and partial closures.
n) I am an employee and my hours have been reduced or I was laid off as a direct result of the COVID-19 public health emergency.
OR Blank space Blank space
o) None of these apply to me. I am unemployed or partially unemployed for another reason not related to COVID-19.

TURN OVER TO SIGN AND COMPLETE THIS FORM

DE 4581PUA Rev. 2 (6-22) (INTRANET)

SAMPLE, this page for reference only.

By signing this form I am declaring under penalty of perjury that the information I have provided, including the reason I am unemployed due to the COVID-19 pandemic, is true and correct to the best of my knowledge or belief. I understand that intentional misrepresentation in self-certifying that I fall within one or more of the COVID-19 categories is fraud and that I may be subject to criminal prosecution if I have been found to have committed fraud to receive Pandemic Unemployment Assistance benefits. I also declare under penalty of perjury that I am a U.S. citizen or national; or an alien in satisfactory immigration status and permitted to work by USCIS. I signed this form after the latest date for which I am claiming benefits.

 
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Your signature is required.

THE FOLLOWING IS IMPORTANT INFORMATION ABOUT YOUR CLAIM:

If you are eligible to be paid PUA benefits and receive payments by check, your check will be mailed in a separate envelope.

MAIL THIS COMPLETED FORM IN THE ENVELOPE PROVIDED TO:

UIC Trade Center
PO BOX 989884
WEST SACRAMENTO, CA 95798-9894

THE FOLLOWING ARE EXAMPLES FOR HOW TO COMPLETE THE ANSWERS ON THE REVERSE SIDE OF THIS FORM:

MARK THE CORRECT ANSWER
EXAMPLE: IF THE ANSWER IS "YES":
IF THE ANSWER IS "NO":
Write numbers like this: ‎ 0 1 2 3 4 5 6 7 8 9
EXAMPLE: Report earnings of:
‎(a) $76.10 (b) $342.58 (c) $1050.55,
like this:
(a)
$
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7 
6 
1 
0 
(b)
$
3 
4 
2 
5 
8 
(c)
$
9 
9 
9 
9 
9 

Section A: WORK-SEARCH RECORD

Date Applied Company Name Company Address Person Contacted Type of Work Applied For Results: Please explain
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Section B: NEW MAILING ADDRESS (Mark Question 8 block on reverse side and provide your new address below.)

Blank Box   New phone - include area code: ()
Zip Code:

DE 4581PUA Rev. 2 (6-22) (INTRANET)