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How to fill out the PUA Backdate Request Form - DOL-5168 - Georgia online
Completing the PUA Backdate Request Form - DOL-5168 is an important step for individuals seeking to adjust the effective date of their Pandemic Unemployment Assistance claim. This guide provides clear, step-by-step instructions to help users navigate the form online with confidence.
Follow the steps to complete your request form effectively.
- Click the ‘Get Form’ button to obtain the form and open it in the online editor.
- Fill in your applicant information in Section A. This includes your first name, middle name, last name, mailing address, last four digits of your Social Security Number, apartment/unit number (if applicable), city, state, and zip code.
- In Section B, indicate your request by checking the appropriate boxes. Choose whether you are requesting your PUA claim to be effective as of a specific Sunday date or if you are requesting payments for previous weeks.
- If you are requesting payments for previous weeks, make sure to attach a PUA Weekly Certification Form (DOL-5158PUA) for each week you are claiming.
- Provide a brief explanation for your request regarding the effective date change or payment for previous weeks, in the space provided.
- Sign the form electronically. Note that your electronic signature is equivalent to a handwritten signature for validity, enforceability, and admissibility purposes.
- Enter the date of your signature.
- After completing the form, save your changes, download a copy for your records, or print it for submission.
Complete your documents online to ensure your request is processed efficiently.
Related links form
Claimants seeking to file a backdated claim should email uchelp@pa.gov with the subject line "Back Date Request." The email should include the exact date they were separated from their employer and any relevant information about the separation for the additional weeks the claimant wishes to claim.