Unemployment Insurance Benefits - Booklets and Pamphlets


Unemployment Insurance Benefits - Forms
(click on the Word or PDF icon to view/download)
  • Agreement for Direct Deposit/Information Regarding Direct Deposit (UIB-1091A)  - Use this form to authorize the department to make automatic deposit of the full amount of any weekly UI benefits to your checking or savings account.
Word Icon 151 KB 
  • Cancellation of Direct Deposit (ESA-1126A)  - Use this form to cancel payment of your current UI Benefits to your direct deposit account.
Word Icon 37 KB
  • Certificate of Understanding (UB99-Y)  - This form is to be completed and returned only if instructed by DES Unemployment Insurance personnel to do so. 
PDF icon small 28 KB 
  • Combined-Wage Claim Withdrawal (UB-113) - This form is used to request a cancellation of an Arizona combined wage claim. Please use this form only if instructed to do so by DES Unemployment Insurance personnel 
Word Icon 107 KB
  • Confidential Financial Statement-English (UB-92-A-FF) - This form is to be completed and returned only if instructed by DES Unemployment Insurance personnel to do so.
  • Confidential Financial Statement-Spanish (UB-92-A-FFS) - This form is to be completed and returned only if instructed by DES Unemployment Insurance personnel to do so.

 

Word Icon (342 KB)

Word Icon (342 KB)

  • Eligibility Review Questionnaire (UB-010) - This form is to be completed and returned only if instructed by DES Unemployment Insurance personnel to do so. 
Word Icon 303 KB
  • Name and Address Change Request (UB-108)  - Use this form to notify the Unemployment Insurance office of a change in your address and/or name.
Word Icon 48 KB
  • Record of Claims Filed and Payments Received (UB-1090A) - Use this form to record weekly Unemployment Insurance claims filed and payments received.
Word Icon 75 KB 
  • Report of Illness or Physical Disability (UB-296) - This form is to be completed and returned only if instructed by DES Unemployment Insurance personnel to do so.
Word Icon 40 KB 
  • Request for Reconsideration/Appeal (UB-126) - Use this form to request reconsideration of or file an appeal to a Determination of Deputy or Unemployment Insurance Benefit Overpayment.
Word Icon 197 KB 
  • Weekly Claim for Unemployment Insurance (UI) Benefits
  • Reclamo Semanal para Beneficios de Seguro por Desempleo
  • Instructions for completing Weekly Claim for UI Benefits (view on page 1)
  • Instrucciones para llenar su reclamo semanal para beneficios de UI (view on reverse)

Word Icon 80 KB
Word Icon 86 KB


PDF icon small 38 KB

  • Work Search Log (UB-101A)  - Use this form to record all work search contacts made during each week in which Unemployment Insurance Benefits are claimed.  Periodic reviews are conducted by the Department and you will be asked to provide (by mail or FAX) a record of where you have applied/inquired about employment during a specific time period.
Word Icon 126 KB 
  • Voluntary Election for Federal/State Income Tax Withholding (UB-433-FF) - Use this form to initiate (or stop) the deduction of Federal and/or State tax from your weekly Unemployment Insurance Benefit payments. 
Word Icon 49 KB 

The Department of Economic Security will provide quality and timely language services to customers with
Limited English Proficiency (186 KB PDF) to ensure meaningful access to programs, services and activities.
To receive services in a language other than English, please contact any DES office.

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