UI / DE 1101IDZ

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UNEMPLOYMENT INSURANCE (UI) APPLICATION

Social Security Number:

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SUPPLEMENTAL FORM FOR DISASTER UNEMPLOYMENT ASSISTANCE (DUA) – ATTACHMENT D

Please complete the following if you are unemployed or partially unemployed due to a disaster as you may be eligible for DUA benefits:

Question	Answer
1. Are you unemployed as a direct result of a recent disaster in California, such as an earthquake, flood, mudslide, wildfire, etc?	1. Yes No
If yes:	If yes, answer questions a‑d:
a) Identify the type of disaster.	a) Blank line
b) At the time of the disaster, in which county did you reside?	b) Blank line
c) At the time of the disaster, in which county did you work?	c) Blank line
d) At the time of the disaster, was your unemployment caused by your need to travel through a disaster area? If yes: Identify the disaster county or counties that prevent travel to your job.	d) Yes No Blank line Blank line Blank line
e) Check the following that best applies to you:	e) 1) An Employee who is unable to work as a direct result of the disaster. 2) An individual who was scheduled to start work for an employer, but could not because of the disaster. 3) A self-employed individual who is unable to work as a direct result of the disaster. 4) An individual who intended to begin self-employment, but could not because of the disaster. 5) An individual who became head of household as a result of the disaster.
f) If you selected item e1 or e3 above, how many hours did you work prior to the disaster?	f) Blank line
g) If you selected e3 or e4 above briefly describe how the disaster affected your ability to continue or begin your self-employment.	g) Blank line Blank line Blank line
h) What is the physical address of your business?	h) Street: Blank line City: Blank line State: Blank line ZIP Code: Blank line

DE 1101IDZ (7-11) (INTRANET)