Ub 106 Form – Fill Out and Use This PDF

Name

Social Security Number		Week Ending Date
		(Must be a Saturday)

You may file your weekly claim for UI Benefits on the Internet at AZUI.COM. You can also return this form by fax or mail with the information provided below. Filing on the Internet may result in faster payment of benefits because the mail delivery and processing time would be eliminated.

Guidance for answering the following questions is located on page 2 of this form.

0.	Is your unemployment due to coronavirus 2019 (COVID-19)?	Yes	No
Answer these questions for the week that ended on the date above.
1.	Were you able to work and available for work each regular workday?	Yes	No
2.	Did you look for work? (You MUST report your work search below)	Yes	No

To be considered as actively seeking work you must have looked for work on four different days of the week.

3.	Did you refuse any job offer or referral to work?						Yes	No
4.	Did you work or earn any money, including part-time work?						Yes	No
	The department regularly matches hiring information with employer records. Failure to report
	earnings may result in prosecution and payment of restitution. (If YES, you must answer 4a. and 4b.)
	4a. What were your gross earnings before deductions?					$
	4b. Are you still working? (If NO, check reason for separation, and answer 4b1 and 4b2 below.)						Yes	No
	Lack of work	Quit		Fired or Discharged	Labor Dispute
	4b1. Name of company you separated from:
	4b2. What was your last day of work?
5.	Have you returned to full-time work which will not require you to file any further weekly claims at this time?
	Failure to disclose that you have returned to work may result in prosecution and payment of restitution.						Yes	No

6. Do you choose to skip filing for the week because you did not meet the work search requirements in #2 above

							Yes		No
7. Did you start school or training?							Yes		No
8. Are you currently receiving unemployment benefits from Canada?							Yes		No
I am claiming benefits for the calendar week that ended on Saturday midnight, as shown above. I certify to the following:
I was registered for work and unemployed. The above statements are true and correct to the best of my knowledge.
I have reported all changes in writing. I understand that the law provides penalties for false statements made in
connection with this claim and if any issues arise from my answers above, the department will contact me.
Claimant’s Signature				Date
When completed, fax to:		You may also mail to: Arizona Department of Economic Security
602-364-1210 or 602-364-1211 (Phoenix)			Unemployment Insurance Benefits
520-770-3357 or 520-770-3358 (Tucson)			MD 5895
			P.O. Box 29225
			Phoenix AZ 85038-9225

See page 2 (Instructions) for EOE/ADA disclosures.

You must file a weekly claim each week. A determination will not be made until you file a weekly claim. All weekly claims are for a calendar week which starts at 12:01 a.m. Sunday and ends at 12:00 midnight on the following Saturday. Weekly claims cannot be filed until after the calendar week has ended.

Below is a brief explanation for each of the questions you will be required to answer each week.

1.Were you able to work and available for work each regular workday?

Able to work - You are able to work if you have no mental or physical condition that prevents you from working or accepting work.

Available for work - You are available for work if you do not have any restrictions that would prevent you from looking for or accepting full-time work when offered.

2.Did you look for work? (You MUST report your work search. Four (4) job contacts are required.)

Actively seeking work – You must make an active effort to seek work that you are suited for by experience, education and training. You must look for work on four different days of the week. General inquiries and phone calls should be accompanied by follow-ups, which may include submissions of applications and resumes. If you conduct your work search online, retain electronic copies of e-mail exchanges and/or other electronic evidence as part of your work search records.

3.Did you refuse any job offer or referral to work?

Refusing a job offer or referral to work – you turned down work that was offered to you or you did not report to an employer that you were referred to from the Employment Service office.

4.Did you work or earn any money, including part-time work?

The department regularly matches hiring information with employer records. Failure to report earnings may result in prosecution and payment of restitution. (If YES, you must answer 4a. and 4b.)

4a. What were your gross earnings before deductions?

If you performed any work or earned any money you must report it on your weekly claim. You must report the total amount earned before deductions. Wages must be reported the week in which the work is performed even if you have not been paid yet.

4b. Are you still working?

NO – Lack of work or a Reduction in force – laid off, no more work was available Quit – Voluntarily left employment

Fired, discharged or Let go – Misconduct

Labor Dispute – A dispute or disagreement which results in a strike or lockout at the place of employment. The department will confirm that a labor dispute exists.

5.Have you returned to full-time work which will not require you to file any further weekly claims at this time?

Failure to disclose that you have returned to work may result in prosecution and payment of restitution.

YES - that you are working and earning an income in excess of your weekly benefit amount and do not have to file a weekly claim.

NO - you are still unemployed and wish to continue filing a weekly claim.

6.Do you choose to skip filing for the week because you did not meet the work search requirements in #2 above? If you did not look for work or meet the required contacts, you will be disqualified until you are reemployed and earn eight times your weekly benefit amount. You have the option to skip filing for the week. If you skip filing for the week you will not receive benefits for the week. You will be able to file next week.

7.Did you start school or training? YES - I started school or training. NO - I did not start school or training.

8.Are you currently receiving unemployment benefits from Canada?

YES - you are receiving unemployment Compensation from Canada. NO - you are not receiving unemployment Compensation from Canada.

Equal Opportunity Employer / Program • Auxiliary aids and services are available upon request to individuals with disabilities

•To request this document in alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1 • Disponible en español en línea o en la oficina local