Georgia Department of Labor

Pandemic Unemployment Assistance (PUA) Backdate Request

Complete this form in its entirety to request an effective date on your Pandemic Unemployment Assistance
Backdate Request
(PUA) claim prior to your current established effective date. The Georgia Department of Labor will review
your request and send you a written determination (decision) once complete.

A. Applicant Information
First Name Middle Name Last Name Last 4 Digits of SSN

Mailing Address Street Apt./Unit Career Center

Mailing Address City State Zip

B. Applicant’s Request
Check all that apply.
 I am requesting my PUA claim be made effective as of (select a Sunday date):
 I am requesting payments for previous weeks.
Attach a PUA Weekly Certification Form (DOL-5158PUA) for each week.
I am requesting payment for previous weeks or change to the effective date of my PUA claim because:

Any electronic signature appearing on this form is the same as my handwritten signature for the purposes of validity,
enforceability, and admissibility. By my signature, I certify the information provided is true and correct to the best of my
knowledge and belief. I understand the law prescribes penalties, possible forfeiture of assistance, and/or criminal prosecution for
misrepresentation or concealment of facts in order to obtain or increase assistance for myself or someone else. I understand that
I may be required to repay any Pandemic Unemployment Assistance I am not entitled to receive.
Signature Date

DOL-5168 (10/20)