Form DUA-3 (ETA83) "Weekly Request for Assistance" - Georgia (United States)

What Is Form DUA-3 (ETA83)?

This is a legal form that was released by the Georgia Department of Labor - a government authority operating within Georgia (United States). As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 1997;
  • The latest edition provided by the Georgia Department of Labor;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DUA-3 (ETA83) by clicking the link below or browse more documents and templates provided by the Georgia Department of Labor.

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Download Form DUA-3 (ETA83) "Weekly Request for Assistance" - Georgia (United States)

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FIELD SERVICE OFFICE NO.
Georgia Department of Labor
WEEKLY REQUEST FOR ASSISTANCE
DISASTER NO.
ROBERT T. STAFFORD DISASTER RELIEF AND EMERGENCY ASSISTANCE ACT
APPLICANT'S NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
WEEK CLAIMED
ADDRESS (No., Street, City, State, ZIP Code)
WEEK ENDING DATE
A. APPLICANT REQUEST
YES
NO
1.
During this week, did you work or earn wages in employment or
If YES, complete the following:
self employment?
Name of Employer:
Date(s) worked:
Number of hours worked:
Gross earnings paid: $
Reason for separation:
Job ended
Quit
Discharged
Still working
2.
a. Did you apply for or receive, or would you be eligible to receive if you
had applied for:
1. Unemployment Compensation under any State or Federal law?
If YES, amount of payment: $
If YES, amount of payment: $
2. Any amounts for loss of wages due to illness or disability?
Type of payment:
If YES, amount of payment: $
3. Any type of private income protection?
Type of payment:
If YES, amount of payment: $
4. Any amount as a supplemental unemployment benefit (SUB)?
Type of payment:
If YES, amount of payment: $
b. Were any amounts payable to you from any retirement, pension or
annuity under a public or private plan or system?
Type of payment:
If NO, explain:
3.
Were you able, available and actively seeking work during this week?
If NO, explain:
4.
Did you accept all work offered during this week?
5.
Have you contacted your last employer to determine if work was
If NO, explain:
available during this week?
B. APPLICATION CERTIFICATION
I CERTIFY that the information I have given on this form is correct. 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 which I am not entitled to receive under the Act.
SIGNATURE OF APPLICANT
DATE (Month, Day, Year)
C. STATE AGENCY DETERMINATION
REASON FOR DETERMINATION
Amount of DUA Payment Authorized for the Week:
$
DUA Reduced or Denied for the week Claimed Above.
DUA Termination Date
DATE AUTHORIZED (Month, Day, Year)
SIGNATURE OF STATE AGENCY REPRESENTATIVE
D. APPEAL RIGHTS
Unless a written appeal is filed, this determination becomes final 60 days after it is given to you or is mailed* to you. You may personally file the appeal in
your local office or mail it to that office.
* The sixty days here are measured from the determination "release date", and not the date you received it in the mail.
DUA-3 (ETA 83) (R-5/97)
FIELD SERVICE OFFICE NO.
Georgia Department of Labor
WEEKLY REQUEST FOR ASSISTANCE
DISASTER NO.
ROBERT T. STAFFORD DISASTER RELIEF AND EMERGENCY ASSISTANCE ACT
APPLICANT'S NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
WEEK CLAIMED
ADDRESS (No., Street, City, State, ZIP Code)
WEEK ENDING DATE
A. APPLICANT REQUEST
YES
NO
1.
During this week, did you work or earn wages in employment or
If YES, complete the following:
self employment?
Name of Employer:
Date(s) worked:
Number of hours worked:
Gross earnings paid: $
Reason for separation:
Job ended
Quit
Discharged
Still working
2.
a. Did you apply for or receive, or would you be eligible to receive if you
had applied for:
1. Unemployment Compensation under any State or Federal law?
If YES, amount of payment: $
If YES, amount of payment: $
2. Any amounts for loss of wages due to illness or disability?
Type of payment:
If YES, amount of payment: $
3. Any type of private income protection?
Type of payment:
If YES, amount of payment: $
4. Any amount as a supplemental unemployment benefit (SUB)?
Type of payment:
If YES, amount of payment: $
b. Were any amounts payable to you from any retirement, pension or
annuity under a public or private plan or system?
Type of payment:
If NO, explain:
3.
Were you able, available and actively seeking work during this week?
If NO, explain:
4.
Did you accept all work offered during this week?
5.
Have you contacted your last employer to determine if work was
If NO, explain:
available during this week?
B. APPLICATION CERTIFICATION
I CERTIFY that the information I have given on this form is correct. 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 which I am not entitled to receive under the Act.
SIGNATURE OF APPLICANT
DATE (Month, Day, Year)
C. STATE AGENCY DETERMINATION
REASON FOR DETERMINATION
Amount of DUA Payment Authorized for the Week:
$
DUA Reduced or Denied for the week Claimed Above.
DUA Termination Date
DATE AUTHORIZED (Month, Day, Year)
SIGNATURE OF STATE AGENCY REPRESENTATIVE
D. APPEAL RIGHTS
Unless a written appeal is filed, this determination becomes final 60 days after it is given to you or is mailed* to you. You may personally file the appeal in
your local office or mail it to that office.
* The sixty days here are measured from the determination "release date", and not the date you received it in the mail.
DUA-3 (ETA 83) (R-5/97)