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How to complete your weekly claim for Disaster (Washington)

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EMSX 5712-W (Rev. 2/2022) - ETA 83
How to complete your weekly claim
for Disaster Unemployment Assistance
You must complete a weekly claim for Disaster Unemployment Assistance form for every week you want to claim benefits. Use a
separate form for each week you want to claim DUA benefits. You can mail, fax or submit the form online. See below.
Section A. Applicant information
For Disaster Unemployment Assistance purposes, a week is Sunday through Saturday. When you file your weekly claim, you are
filing for the week that ended the prior Saturday at 11:59 p.m.
For example, the week that ends 2/12/2022, covers Sunday, 2/6/2022, through Saturday, 2/12/2022. File your claim for the week
ending 2/12/2022 anytime starting 2/13/2022. We will return the form to you if it is submitted or postmarked too early.
To prevent a delay in processing your weekly claim, please give complete information on the form. Answer all questions and provide
more information, if needed.
Section B. Work search information
Questions in this section need to be completed if you:
• Worked for an employer; or
• Worked in self-employment and are now looking for work with an employer.
Section C. Self-employment update information
Questions in this section need to be completed if you were self-employed and are making efforts to resume your self-employment.
Describe what you are doing to resume your self-employment.
Section D. Application certification
Read the certification. Sign and date the form. We cannot accept a form that is not signed.
Submit your weekly claim form by on our website or by fax or postal mail:
• Online: Go to esd.wa.gov/dua
and look for the secure upload link.
• Fax: 844-395-6712.
• Mail:
Employment Security Department
Disaster Unemployment Assistance
PO Box 19019
Olympia, WA 98507-0019
To submit your weekly claim by phone or ask questions, call the Disaster Unemployment Assistance Unit at 855-952-9988.
EMSX 5712-W (Rev. 2/2022) - ETA 83
Disaster no.:
FEMA - 4635 - DR
WEEKLY CLAIM FOR DISASTER UNEMPLOYMENT ASSISTANCE
Social Security number:
Applicant name:
Mailing address:
Use a separate form for each week you want to claim.
Additional forms available at esd.wa.gov/dua.
Filing for the week ending (must be a Saturday date):
Please write legibly. Your benefits may be delayed or denied if you fail to answer all questions or if we can’t read your entry.
Answer the following questions for the week you are claiming. If you need more space, use a separate piece of paper and attach it.
A. Applicant information
Earnings Number of hours
1. Did you work for an employer during the week? If “Yes,” enter
the gross earnings for the number of hours you worked in the
week you are claiming.
Yes No
Employer’s name: Contact name:
City: State: ZIP code: Phone number:
2. Did you work in self-employment during the week?
If “Yes,” enter the net earnings for the hours y
ou
w
orked in the week you are claiming.
Yes No
Earnings Number of hours
3. Were you able to, and available for, work each day during
t
he week you are claiming? If “No,” explain why not in the
box to the right.
Yes No
4. Did you apply for, or receive any of, the following during
the week?
If “Yes,” complete section to the right of question.
Amount
Type/Source
of payment
Period covered
From To
a. Vacation, sick or holiday pay? Yes No
b. Unemployment benefits under any state, federal or
railroad law?
Yes No
c. Loss of wages due to illness or disability (worker’s
compensation)?
Yes No
d. Private income protection insurance or supplemental
unemployment benefits?
Yes No
e. Retirement pay, such as 401(k) or pension? Do not
report Social Security.
Yes No
EMSX 5712-W (Rev. 2/2022) - ETA 83
To be eligible for a week of Disaster Unemployment Assistance benefits, you must show that you are making every reasonable effort
to find work or resume your self-employment.
B. Work search information
Only fill out this section if you worked for an employer, or you were self-employed and are now looking for a job with an employer.
1. Were you offered work during the week?
If “Yes,” answer question 2. Yes No
2. Did you accept all work you were offered during the week?
If “No,” explain:
Yes No
3. Did you contact your last employer to see if work was available during the week?
If “No,” explain:
Yes No
4. List the employers you contacted for work during the week you are claiming. Enter all the information requested in each column.
You must complete 1 activity, rows 2 and 3 are optional.
Date of
contact
Employer’s name and address
Name of the
person you
talked to
How you made
the contact (in
person, online,
phone)
Type of work
you asked for
What did the employer tell you
about the possibility of a hire?
submit an
application
or resume?
Was this
a new
contact?
(Yes/No)
C. Self-employment update information
Fill out this section only if you were self-employed.
Please describe in detail what measures you are taking to resume your self-employment during the week. If you are not trying to
resume your self-employment, explain what you are doing to find a job and complete section B above.
D. Application 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:
Phone:
Date:
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Completed 15 February 2022

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