NDOL | PUAWeeklyCertForm

Recertification for Pandemic Unemployment Assistance (PUA) Benefits

Use this form only to certify weeks of PUA for which you were previously denied benefits

First Name

Claim Number

Last Name

Last 4 of SSN

Self-Certification Declaration

To qualify for PUA, you must be unemployed, partially unemployed, or unable or unavailable to work because of one or more of the COVID-19 reasons. Please select the Add a Week button below to file for each PUA week you are seeking to claim.

Claim Week(s) Being Certified

Misrepresentation

I certify that the information I have given on this form is correct. I have supplied the information voluntarily in order to potentially obtain Pandemic Unemployment Assistance.

I acknowledge and understand that: a) making this certification is under the penalty of perjury; b) intentional misrepresentation in self-certifying that I am affected by COVID-19 in one or more of these categories is fraud; and c) if it is determined that I have committed fraud, I may be subject to criminal prosecution.

Certification

I certify that the information I have given on this form is correct. I have supplied the information voluntarily in order to potentially obtain Pandemic Unemployment Assistance

Signature

Sign Date

4/25/2024

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