To be eligible for DUA, you must be ineligible for a regular unemployment benefit
claim. To file a claim for Disaster Unemployment Assistance: 1. Complete the ...
INSTRUCTIONS FOR FILING A CLAIM FOR DISASTER UNEMPLOYMENT ASSISTANCE (DUA) Disaster Unemployment Assistance (DUA) is available if you are temporarily unemployed due to a direct result of a federally-declared major disaster. To be eligible for DUA, you must be ineligible for a regular unemployment benefit claim. To file a claim for Disaster Unemployment Assistance: 1. Complete the enclosed “Initial Application for Disaster Unemployment Assistance,” and the “Disaster Unemployment Assistance (DUA) FactFinding Questionnaire.” 2. If you are Self-Employed or a Corporate Officer/Owner also complete the “Supplement to Application for DUA Self-Employed Individuals,” or the “Supplement to Application for DUA – Corporate Officer/Owner” whichever applies. 3. Provide the required proof of employment and wages (see below) within 21 days of the filing of your claim to avoid denial of continued benefits and a demand for refund of any benefits received before then. You must also provide proof of dependents if you are claiming dependency benefits. No dependency benefits will be paid until proof is provided. If you do not have the necessary documents, contact the FEMA Center for rapid assistance. FEMA telephone: (800) 621-FEMA (3362) Declaration Number: FEMA-4086-DR 4. Mail or FAX the application with corresponding forms and proof of employment to: New Jersey Department of Labor and Workforce Development Division of Unemployment Insurance Collateral Claims Unit PO Box 395 Trenton, NJ 08625-0395 Telephone: (609) 984-4358 FAX: (609) 984-2284 Examples of Acceptable Proof: Regular Employment
Self-Employment or Owner of a Corporation
W-2 Forms Pay Stubs Pay Envelopes IRS Form 1040 (only if filed as an individual)
Business Income Tax Returns for last year including Form 1040 plus one or more of the following: Schedule C, “Profit or Loss from Business…” Schedule C-EZ, “Net Profit from a Business…” Schedule F, “Profit or Loss from Farming” _____________________________________________________________________________________________ STATEMENT REQUIRED UNDER THE PRIVACY ACT OF 1974 FOR THE DISASTER UNEMPLOYMENT ASSISTANCE (DUA) PROGRAM
While all of the information requested on the DUA application and payment request forms is voluntary, most of the information (including your Social Security Account Number) is required in order to promptly process your claim for DUA. All of the information requested (including the Social Security Account Number) will be used for statistical and research purposes by the New Jersey Department of Labor and Workforce Development, Division of Unemployment Insurance, and the U.S. Department of Labor. Information requested for use by the New Jersey Department of Labor and Workforce Development, Division of Unemployment Insurance, and the U.S. Department of Labor is authorized under Section 407 of the Disaster Relief Act of 1974 (42 U.S.C. 5177) and Section 906 of the Social Security Act (42 U.S.C. 1106). All information furnished will be confidential except to the extent that release of such information is authorized in the processing of your claim, and will not be released or used for any purpose other than for establishing your entitlement for DUA, for statistical and research studies, and to insure that benefits have been paid properly. (R‐11‐12)
INSTRUCCIONES PARA PRESENTAR UN RECLAMO PARA ASISTENCIA DE DESEMPLEO DEL DESASTRE (DUA) Asistencia de desempleo del desastre (DUA) está disponible si estás tempoalia mente desempleado debido a un resultado directo de un desastre declarado por el Gobierno Federal. Para ser elegible para DUA, debe ser elegible para una reclamación de beneficios de desempleo regular. 1. a presentar una solicitud de asistencia para desastres en desempleo: completar la "solicitud de inicial de desempleo del desastre asistencia" y el cuestionario de investigación de asistencia de desempleo del desastre (DUA). " 2. Si eres autónomo o un propietario de oficial corporativo también completar el "suplemento a aplicación para DUA auto empleado Individual" o el "suplemento a aplicación de DUA – corporativa oficial/propietario" corresponda. 3. Proporcionar la prueba de empleo y salarios (ver abajo) dentro de 21 días de la presentación de su reclamo para evitar la denegación de beneficios continuas y una demanda de reembolso de las prestaciones recibidas antes de esa fecha. También debe proporcionar prueba de dependientes si usted solicita beneficios de dependencia. Ninguna dependencia se pagarán beneficios hasta comprobante. Si no tiene los documentos necesarios, póngase en contacto con el centro de FEMA para ayuda inmediata. Teléfono FEMA: (800) 621‐FEMA (3362) declaración número: FEMA‐4086‐DR 4. Correo o por FAX la solicitud con los formularios correspondientes y prueba de empleo Nueva Jersey Departamento del trabajo y de la fuerza laboral Develpoment División de Une, Authorization seguro Oficina de DUA – unidad de reclamos colateral PO BOX 395 Trenton, NJ 08625‐0395 Telefono: (609) 984‐2284 FAX: (609) 984‐4358 Ejemplos de prueba aceptable: autoempleo o propietario de una emppresa Empleo Regular Impuesto sobre la renta empresarial devuelve el ano pasado Formularios W‐2 Schedule C, Ganancia o perdida de negocios” Talonarios Schedule C EZ, “Ganancia neta de un negocio” Sobres de pago Schedule F, “ganancia o perdida de la agricultura” IRS Form 1040 (sólo si se presentó como un individuo)
DISASTER UNEMPLOYMENT ASSISTANCE (DUA) FACT-FINDING QUESTIONNAIRE APPLICANT’S NAME: SS#: Please complete all items. Failure to complete all items may delay processing of your claim. 1. Please provide a telephone number where you can be reached in case we need to contact you to clarify your answers. Home Telephone No.: (
)
-
Work Telephone No.: (
Temporary telephone number due to the disaster: (
)
2. Was your unemployment a direct result of the disaster?
)
-
-
Yes
No
3. State the specific cause of unemployment.
4. a. Did you contact your employer to see if work is available for you?
Yes
No
b. If yes, what date(s) did you contact your employer? 5. a. On what dates was work available? b. Did you accept all work available to you? c.
Yes
No
If no, why not?
6. a. If work was available with your employer, did you stay home from work solely to attend to the disaster-related damage to your home? Yes No b. If yes, what dates? 7. a. Was your primary means of transportation to work available?
Yes
No
If no, state why and the dates it was unavailable. b. Were alternate means of transportation available?
Yes
If yes, did you use those alternate means of transportation?
No Yes
No
If no, state why. c.
If you do not have transportation, is it because you left the area to stay somewhere other than an evacuation center? Yes No
8. a. Were/Are the roads you use to go to work open?
Yes
No
If no, state which roads were closed and the dates they were closed. b. Were alternate routes to go to work available? c.
If yes, did you use the alternate routes?
Yes
Yes
No
No
If no, state why. DUA-7 (R-8-00) New Jersey Department of Labor – Unemployment Insurance
(See Reverse)
9. a. Did you or will you receive payment for any period after your last day of work?
Yes
No
b. If yes, what does this payment represent (sick, holiday, vacation, etc.) and who is this payment from?
c.
List the days you are being paid for and the gross amounts. Date(s)
Paid
Date(s)
Paid
Date(s)
Paid
Date(s)
Paid
Date(s)
Paid
Date(s)
Paid
Date(s)
Paid
Date(s)
Paid
10. a. Are you receiving a pension or other retirement pay?
Yes
No
If yes, what type of payment are you receiving and what is the amount? 11. a. If you were not employed at the time of the disaster, did you have a definite promise to begin work? Yes No b. If yes, what date were you to start? c.
Name, address, and phone number of the company.
12. a. Were you injured as a result of the disaster?
Yes
No
b. If yes, what is the injury? c.
What is the period of disability?
d. Did the injury prevent you from working? Yes requested). 13. a. Are you a full-time student?
Yes
No
(Doctor’s statement must be provided if
No
b. If yes, show name of school and number of hours in attendance per week.
I certify that the information I have given on this form is correct, and that I have supplied the information, voluntarily, in order to obtain DISASTER UNEMPLOYMENT ASSISTANCE. I know that Federal funds are provided and that penalties are prescribed by law for willful misrepresentation or concealment of material facts in order to obtain assistance payments to which I am not entitled to receive under the Act. Applicant’s Signature
Date
Deputy’s Signature
Date
FOR OFFICE USE
NEW JERSEY DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
INITIAL APPLICATION FOR DISASTER UNEMPLOYMENT ASSISTANCE (DUA) Applicant’s Name (Last, First, Middle)
Social Security No.
Street Address
Local Office No.
Residence FIPS
FEMA No.
Date Filed
Last Day Worked
Announcement Date Yes*
Are you a student?
City
State
Zip Code
County Name
Do you have a disability? Yes
No
Yes
No
Are you a U.S. Citizen?
Refused
If “No” Alien Registration No. __________________________
Date of Birth (Mo., Day, Yr.,)
Telephone No. ( )
No
Sex Male Female
Ethnic Group (For Statistical Purposes Only). Indicate by selecting one of the following: Hispanic or Latino
Race (For Statistical Purposes Only). Indicate by selecting one of the following: White Black or African American Asian American Indian or Alaska Native Pacific Islander or Native Hawaiian Choose not to answer
Choose not to answer
A. SELF-EMPLOYED APPLICANTS (Complete this form and also Supplement to Application for DUA Self-Employed Individual) If all income is from a business or farm that is incorporated you are not considered self-employed. At the time of the disaster: 1. a. Were you self-employed?
Yes
No
If “Yes”, date self-employment began? ____________________________
b. If you were not self-employed, were you to begin self-employment? Yes* No B. CORPORATE OFFICER APPLICANTS Yes
1. Are you a corporate officer (including S Corporations) or an owner of a corporation?
No
C. EMPLOYED APPLICANTS As a result of the disaster: 1. Was your place of employment closed?
Yes
No
If “Yes”, reason for closure ______________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Date Closed _____________________ Date Reopened _____________________ 2. Were you unable to reach your place of employment? Yes
No
D. ALL APPLICANTS 1. Were you injured as a result of the disaster? 3. Were you to start a new job? Reason you could not start:
Yes
No
Yes
No
2. Did you become the head of a household due to a death caused by the disaster? Yes* No
If “Yes”, date you were to begin work _____________________________________
Unable to reach job
Business closed
Other*
Rate of pay you were to receive $ _____________________ per _______________
Number of hours per week you were to work ________________________________
Name and address of prospective employer _______________________________________________________________________________________ _______________________________________________________________________________________ _________________________________________________________ County Name:__________________ Telephone No. (
)_______________________________________________
E. OTHER COMPENSATION Have you applied for or will you receive:
Applied
Receiving
Period Covered (Mo., Day, Yr.) To From
Monthly Amount
Any state, federal or railroad UI?
Yes
No
Yes
No Pending
$ _______________
___________________
___________________
Compensation for disability or illness?
Yes
No
Yes
No Pending
$ _______________
___________________
___________________
$ _______________
___________________
___________________
$ _______________
___________________
___________________
$ _______________
___________________
___________________
Private income protection insurance? Holiday or vacation pay?
Yes Yes
No No
Yes Yes
Yes No Yes Pension or retirement benefits? (Not including Social Security) F. EMPLOYER (OR BUSINESS) NAME AT THE TIME OF THE DISASTER
No Pending No Pending No Pending
Dates of Employment
Street Address City
From Zip Code
State
To
County Name
Telephone No. ( )
Occupation with this Employer
Next Date You Would Have Worked if Not for Disaster (Mo., Day, Yr.)
G. APPLICANT EMPLOYMENT OR SELF-EMPLOYMENT DURING TAX YEAR __________________________ (MOST RECENT TAX YEAR PRIOR TO DISASTER) 1. Name and Address of Employer (Check if Self-Employment )
No. of Hours Worked Per Week
Telephone No, ( ) Period Worked: From
Weekly Wage
Documentation To
Total Earnings or Net Income from Self-Employment ** No. of Weeks Earnings Equal or Exceed $145 2. Name and Address of Employer (Check if Self-Employment )
No. of Hours Worked Per Week
Telephone No, ( ) Period Worked: From
Weekly Wage
Documentation To
Total Earnings or Net Income from Self-Employment ** No. of Weeks Earnings Equal or Exceed $145 DUA-81 (R-4-10) NEW JERSEY DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT – UNEMPLOYMENT INSURANCE
*Explain in “Remarks.” **Self-employment: Include all net income from non-incorporated self-employment. Do not include income that is on Internal Revenue Service Form 4835 or Form 4797.
No. of Hours Worked Per Week
Telephone No, ( )
3. Name and Address of Employer (Check if Self-Employment )
Period Worked: From
Weekly Wage
Documentation To
Total Earnings or Net Income from Self-Employment ** No. of Weeks Earnings Equal or Exceed $145
H. CLAIM FOR DEPENDENCY BENEFITS Under the provisions of the NJ Unemployment Compensation Law, you may be entitled to a dependency allowance for a maximum of three dependents. You must supply the social security number of your spouse, civil union partner or an unemployed, unmarried child (including stepchild or legally adopted child) under the age of 19 (or 22 if the child is attending school full-time). You are required to provide proof of dependency for the children listed as dependents. The Division will accept as verification of dependency status the claimant’s most recent federal or state income tax return. If this is unavailable, or insufficient to prove current dependency status, the Division may consider a combination of the following documents: birth, baptismal or marriage certificate(s); civil union license(s); certified divorce, dissolution; child support, annulment or adoption order(s) or any other legal documents. Please send photocopies. Do not send originals. You must provide proof within six (6) weeks of the date of claim or you will be ineligible to receive dependency benefits for the duration of the claim. NO DEPENDENCY BENEFITS WILL BE PAID UNTIL PROOF IS PROVIDED TO THE DIVISION. If you wish to claim dependency benefits, complete a., b., and c. below. a. Are you legally married? Yes No If yes, is your spouse/civil union partner employed? Yes No IF YOUR SPOUSE/CIVIL UNION PARTNER IS EMPLOYED AT THE TIME THIS CLAIM TAKES EFFECT, YOU WILL NOT BE ELIGIBLE FOR A DEPENDENCY ALLOWANCE. b. If you are claiming dependents, please complete the following information: LOCAL OFFICE USE ONLY
DEPENDENT’S NAME IF MARRIED OR IN A LEGALLY SANCTIONED CIVIL UNION, LIST SPOUSE/CIVIL UNION PARTNER FIRST
c.
I.
AGE
SOCIAL SECURITY NO.
RELATION TO YOU
MARRIED/IN A CIVIL UNION
EMPLOYED
YES
YES
NO
ELIGIBLE YES/NO
VERIFICATION PROVIDED
BY
NO
If any of the above-listed dependent children over age 18 attend a public or other nonprofit educational institution on a full-time basis, please specify which individual(s) and provide the name(s) of the school(s).
Federal Income Tax Withholding Disaster Unemployment Assistance (DUA) benefits are considered taxable income for federal income tax purposes. Federal regulations exist regarding the payment of estimated taxes, on a quarterly basis, on income that is not subject to tax withholding. Penalties may be imposed, by the Internal Revenue Service, if you do not pay enough tax through withholding and/or by making estimated tax payments. To help offset future tax liabilities, you may voluntarily choose to have 10% of your weekly unemployment benefits withheld and forwarded to the Internal Revenue Service. You may change your withholding status at any time by writing to your unemployment insurance office. If you wish to have Federal Income Tax withheld from your weekly benefits, check the box below.
I elect to have Federal Income Tax withheld from my payments in an amount equal to 10% as specified in the Federal Internal Revenue Code.
J. Remarks ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________
I CERTIFY that all of the information I have given on this application and forms related to this application is correct to the best of my knowledge and belief, and that I have supplied this information in order to obtain DISASTER UNEMPLOYMENT ASSISTANCE (DUA). I understand that federal funds are provided and that under 18 U.S.C. 1001 I may be subject to prosecution for willfully concealing material facts or knowingly making a false statement to obtain DUA to which I am not entitled. I am furnishing my Social Security Number as required under 26 U.S.C. 6109(d) for purposes of reporting DUA as federal taxable income and for determining my entitlement to DUA. I UNDERSTAND, in accordance with 20 CFR 625.16(b), that information concerning my DUA application may be disclosed only as is allowed with respect to regular compensation under state law and to the U.S. Department of Labor. Signature of Applicant ______________________________________________________________________ Date ______________________________
Signature of Deputy _______________________________________________________________________ Date ______________________________
NEW JERSEY DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT SUPPLEMENT TO APPLICATION FOR DUA SELF-EMPLOYED INDIVIDUALS (NOT INC.) Applicant’s Name (Last, First, Middle)
Disaster No.
Local Office No.
FEMA -
Social Security No.
- DR
TYPE OF SELF-EMPLOYMENT (Check Appropriate Boxes)
Business Name and Address (No. Street, City, State, Zip Code)
ENGAGED IN: Farming
Business
Profession
AS A: Sole Owner Size of Farm (In Acres):
A. FARMING ACTIVITY (If applicable)
Percentage of Ownership
Partner
In columns below, list all farm products raised and held permanently for sale and farm income. CROPS
LIVESTOCK
KIND
ACRES
KIND
OTHER (Specify) INCOME
KIND
INCOME
B. SELF-EMPLOYMENT INFORMATION (Answer all questions in this part) 1.
Describe the nature of your self-employment; indicate how long you have been performing it.
2.
a.
What are the days and hours of normal operation of your business?
b.
What days and hours did you actually work?
3.
Yes
Did you have any partners?
No
If yes, please provide the following information Name
4.
Social Security No.
Did you have other employees prior to the disaster?
Percentage of Ownership
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If yes, how many and what is their current employment status? 5.
a.
What were your duties and normal days and hours of work?
b.
Were you performing those duties at the time of the disaster? If no, please explain.
6.
How did the disaster impact your self-employment (damages, lost jobs, lost income, etc.)?
7.
Do you plan to reopen this business? If yes, on what date and what have you done to restore your business?
If no, please explain and what are you doing or what do you plan to do to secure employment?
8.
Have you applied for FEMA, SBA or other assistance? If yes, please explain why.
9.
a.
Were you self-employed part-time prior to the disaster? If yes, please explain why.
b.
Do you restrict yourself to part-time work? If yes, why?
SEE REVERSE DUA-81A (R-4-10) NEW JERSEY DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT – UNEMPLOYMENT INSURANCE
10.
Was your self-employment your primary source of earned income?
Yes
No
Yes
No
Yes
No
If no, explain.
11.
At the time of the disaster, did you or do you now have any business, business location(s), or occupation (job), other than the self-employment at this location? If yes, provide name and address of business, business location(s) or occupation.
Describe the effect the disaster has had on this other business/location(s)/occupation.
What is the current gross income from this other business/location(s)/occupation? 12.
Did you receive or will you receive any income continuation pay, business interruption insurance, or any other wage replacement income? If yes, complete the following information: Type of Payment
Amount
13.
What was your gross income for the business in the tax year of
14.
Was your business seasonal?
Time Period Covered
? Yes
No
Yes
No
Yes
No
If yes, between what dates was your business normally in operation in prior years? C. FAMILY BUSINESS INFORMATION 1.
Were you employed in a family business prior to the disaster date?
2.
How many adults were employed in the family business prior to the disaster date?
3.
How many minors (not adults) were employed in the family business prior to the disaster date?
4.
Were you a minor employed in a family business prior to the disaster date?
5.
The tax year for the family business started
and ended
You must complete the following questions. Your DUA rate will be based on an equal rate for each adult family member. If you feel that your DUA rate should be based on a rate higher than an equal portion of the net family business income, you must provide a percentage of net income for all family members of the business. Include income for minors employed in the family business. MEMBERS OF FAMILY BUSINESS
SOCIAL SECURITY NUMBER
PERCENTAGE OF WAGES OF FAMILY BUSINESS
D. APPLICANT EMPLOYMENT In order to compute the amount of my weekly entitlement to Disaster Unemployment Assistance. I certify that I had the following selfemployment, net earnings during the tax year (the most recent tax year prior to the disaster.) Family businesses must indicate the entire family business income. If the information below was provided on the DUA-81, enter “SAME” in the appropriate blocks. (Report net earnings from self-employment – DO NOT REPORT GROSS EARNINGS.) For Office Use Weeks Earned Name and Address of Business Net Earnings Documentation or Other $145 or More Proof of Earnings
Total Weeks
Total Earnings
E. APPLICANT CERTIFICATION I CERTIFY that the information I have given on this form is correct, and that I have supplied the information, voluntarily, in order to obtain DISASTER UNEMPLOYMENT ASSISTANCE. I know that Federal funds are provided and that penalties are prescribed by law for willful misrepresentation or concealment of material facts in order to obtain assistance payments to which I am not entitled to receive under the Act. Signature of Applicant
Signature of Agent
Telephone No.
Date
Date
NEW JERSEY DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT SUPPLEMENT TO APPLICATION FOR DUA CORPORATE OFFICER/OWNER ( INCLUDING “S” OR OTHER CORPORATION) Applicant’s Name (Last, First, Middle)
Disaster No. FEMA -
Local Office No.
Social Security No.
- DR
TYPE OF CORPORATION (Check Appropriate Boxes)
Business Name and Address (No. Street, City, State, Zip Code)
ENGAGED IN: Farming
Business AS A:
Profession Percentage of shares/business owned
Title:
1.
What is the nature of your business and when was it established?
2.
What were your job duties and normal work days prior to the disaster?
3.
Please provide the following information for the other officers/owners. Name
4.
Social Security No.
Title
Percentage of shares/business owned
Was this business in operation at the time of the disaster?
Yes
No
Were you performing your duties at the time of the disaster?
Yes
No
5.
What were the normal days and hours of operation of this business prior to the disaster?
6.
What was the gross income per week of this business prior to the disaster?
7.
What was the impact of the disaster on this business (damages, lost income, etc.)?
8.
Did you receive or will you receive income continuation pay, business interruption insurance, or any other wage replacement income?
Yes
No
Yes
No
If yes, list type and amount. 9.
Did you have any employees? If yes, how many and what is their current employment status?
SEE REVERSE DUA-81C (R-11-09) NEW JERSEY DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT – UNEMPLOYMENT INSURANCE
Yes
No
Yes
No
12. Is this a part-time business?
Yes
No
13. Do you restrict yourself to part-time work?
Yes
No
Yes
No
10. Do you plan to reopen? a.
If yes, detail what actions you have taken or are taking towards reopening this business.
What date do you expect to reopen? b.
If no, what are you doing or what do you plan to do to secure employment?
11. Have you applied for FEMA, SBA, or other assistance? Please explain.
If yes, why?
14. At the time of the disaster, did you or do you now have any business, business location(s), or occupation (job), other than the one listed above?
If yes, give name and address of business, business location(s), or other occupation (job), and gross income of that business/occupation.
Yes
15. Was this a seasonal business?
No
If yes, between what dates was it normally in operation in prior years?
I CERTIFY that the information I have given on this form is correct, and that I have supplied the information, voluntarily, in order to obtain DISASTER UNEMPLOYMENT ASSISTANCE. I know that Federal funds are provided and that penalties are prescribed by law for willful misrepresentation or concealment of material facts in order to obtain assistance payments to which I am not entitled to receive under the Act. Signature of Applicant
Signature of Agent
DUA-81C (Back)
Telephone No.
Date
Date
