SAMPLE, this page for reference only

HEAD OF HOUSEHOLD INFORMATION

1. QUESTIONS FOR HEAD OF HOUSEHOLD:
   1. Did the head of the household die as a direct result of the disaster?
      yes no
   2. Have you become the major support of the household?
      yes no
   3. Have you entered the labor market and begun seeking employment?
      yes no
   4. Is there any reason you cannot accept full-time employment?
      yes no
2. INFORMATION REGARDING DECEASED HEAD OF HOUSEHOLD:
   1. Blank line 

      Name

      XXX- XX- Blank space

      Social Security Number
   2. Blank line 

      Date of Death

      (Provide Death Certificate or Incident Report)
   3. Please provide circumstances of death of head of household.
      Blank Line
      Blank Line
      Blank Line
      Blank Line
      Blank Line
      Blank Line

I certify that I am the only family member applying for Disaster Unemployment Assistance (DUA) benefits on the basis of becoming the major support for the household because the head of the household died as a direct result of the major disaster.

DE 8597 Rev. 1 (8-21) (INTRANET)