UI / DE 4581DUAU

SAMPLE, this page for reference only

ALLOW 10 DAYS FOR DELIVERY OF CHECK.
DETACH THIS STUB FOR YOUR RECORD

CONTINUED CLAIM

ANSWER ALL QUESTIONS. SEE SECTION A. ON BACK FOR EXAMPLES OF HOW TO COMPLETE YOUR ANSWERS. Each question is explained in your booklet, A Guide to Benefits and Employment Services 1ST WEEK 2ND WEEK
BEGIN
ENDS		 BEGIN
ENDS
YES NO YES NO
COMPLETE AND MAIL THIS FORM ON
1. Were you too sick or injured to work for reasons other than the disaster?
  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 disaster) 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?
4. Did you refuse any work?
5. Did you receive disability, private income insurance, or supplemental unemployment benefits?
6. Did you work or earn 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. D on reverse.
 
I understand the questions on this form. I know the law provides penalties if I make false statements or withhold facts to receive benefits; my answers are true and correct. I 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.
X
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(your signature is required)
DE 4581-DUAU Rev. 6(5-04) (INTRANET)

DETACH AND DISCARD