The questions marked with an asterisk (*) must be completed to submit the documents. Language English Authorization Number * First Name * Middle Initial Last Name * Phone Number * Email Address * Re-Enter Email Address * Last 4 of Social Security Number * xxx-xx Month and Day of Birth Year18821883188418851886188718881889189018911892189318941895189618971898189919001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day What is the reason for your unemployment (please pick the item that best fits your situation)? * (20) I have been diagnosed with COVID-19 or am experiencing symptoms of COVID-19 and am seeking a medical diagnosis. (21) A member of my household has been diagnosed with COVID-19. (22) I am providing care for a family member or a member of my household who has been diagnosed with COVID-19. (23) A child or other person in my household for whom 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. (24) 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. (25) 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. (26) 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. (27) I have become the breadwinner or major support for a household because the head of the household has died as a direct result of COVID-19. (28) I quit my job as a direct result of COVID-19. (29) My place of employment is closed as a direct result of the COVID-19 public health emergency. (31) I am self-employed (including an independent contractor and/or gig worker) and experienced a significant reduction of my customary or usual services because of the COVID-19 public health emergency. (32) 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. (33) 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. (34) 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. (35) None of the above apply to me (please uncheck any other selections you may have made). *Did your employer give you the option to work from home (telework)? * Yes No Explain why you were unable to work from home * Date you became head of of household * Please provide a copy of the death certificate/ obituary or documentation that supports the evidence of the deceased. Upload More informationFiles must be less than 5 MB. Allowed file types: gif jpg jpeg png txt rtf pdf doc docx xls xlsx. Please provide evidence of job offer. Examples include offer letter, email, or other documentation that supports the evidence of the job offer. Upload More informationFiles must be less than 5 MB. Allowed file types: gif jpg jpeg png txt rtf pdf doc docx xls xlsx. Provide a detailed explanation for why you are filing an unemployment insurance claim * Select the type of employment you lost. * I worked for an employer/business/company I was self-employed I was a contract worker Latest Employment Name of the business or company * Type of business (Ex: A restaurant, dental office, construction, hairstylist) * Job Title * Explain in detail the type of work you performed. * Enter the date you began working in this employment. * Enter the date you last performed work in this employment. * Are you receiving any sick pay, vacation pay or other paid leave? * Yes No Enter the date you are being paid through. * (Note: When filing your weekly claim, you must report any sick pay, vacation or other paid leave during the week to which it applies.) Are you a full-time or part-time employee? * Full-time Part-time Prior to COVID-19, how many hours on average do you work per week * Scheduled to be Employed Employer Name: * Employer Address: * Employer Phone: * Date you were to start new employment: * Your wage history needs to be established. You will need to provide proof of wages when you submit this request for reconsideration. If your employment was impacted by COVID-19 in 2020, please provide the following documents for year 2019 If your employment was impacted by COVID-19 in 2021, please provide the following documents for year 2020 This can be done by uploading any of the following documents: Federal Tax Return Please included the following when applicable: Schedule C-Profit or Loss from Business Schedule F-Profit or Loss from Farming Schedule K 1- Partner's Share of Income Form 1099 - Miscellaneous Income Only Form W-2 Final pay Stub If self-employed: Invoice, Billing, or Other Documentation to Provide Proof of Self-Employment If you do not have any of the above, you can provide the last Federal tax return you filed. Note: If you are unable to provide complete proof of wages, you will only be allowed the minimum PUA payment. Once you are able to provide your proof of wages, your claim will be redetermined. If the redetermination results in a higher amount, we will adjust your payments. Included File * Upload More informationFiles must be less than 5 MB. Allowed file types: gif jpg jpeg png txt rtf pdf doc docx xls xlsx. Included File 2 Upload More informationFiles must be less than 5 MB. Allowed file types: gif jpg jpeg png txt rtf pdf doc docx xls xlsx. Included File 3 Upload More informationFiles must be less than 5 MB. Allowed file types: gif jpg jpeg png txt rtf pdf doc docx xls xlsx. After you click the Submit button, you will receive a confirmation email. Your documents are not received until you receive this confirmation email. Please retain a copy of the confirmation email as proof of your submission. If you do NOT receive the confirmation email, or if you are for any other reason unable to complete the document upload process, you must mail, fax or email your documents. Once a document is uploaded/submitted, it will become the property of IWD. IWD-PUA 1000 E Grand Ave. Des Moines, IA 50319 Fax: 515 242-0494 If you knowingly make or cause another to make a false statement or knowingly fail or cause another to fail to disclose a material fact and as a result you receive Pandemic Unemployment Assistance to which you are not entitled, you shall be subject to prosecution under section 1001 of title 18, United States Code. Certification To deter and detect fraud, Iowa Workforce Development randomly audits claims. If you knowingly make or cause another person to make a false statement or knowingly fail or cause another person to fail to disclose a material fact and as a result you receive benefits to which you are not entitled, you will be subject to prosecution under section 1001 of title 18, United States Code. I certify statements I have made on this application and all attachments to it are true, accurate, and complete to the best of my knowledge and belief. Required Certification * I certify and agree that the application I have submitted (and attachments) are true, accurate, and complete to the best of my knowledge and belief. Leave this field blank Submit Individual
