Unemployment Assistance

UIA-4

Name *

First

Last *

Last

Phone *

Email *

Address (including any apt, lot, or unit number) *

City *

State *

ZIP *

UIA Claim number *

Letter number of last correspondence from UIA *

Date first became unemployed *

Date you originally filed claim *

Have you received any payments?

Yes

No

If you are missing payments, how many?

Are you able to certify your weeks?

Yes

No

Have you been unable to certify for more than 4 weeks?

Yes

No

Have you been paid in the last four weeks?

Yes

No

Have you received an Overpayment/Restitution letter?

Yes

No

Date of the Overpayment/Restitution letter?

Brief description of current issue with claim, status of claim *

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