Unemployment Assistance

In order to better assist you, please fill out this form completely. The more information we have, the sooner we can submit your request to the Pennsylvania Department of Labor and Industry. If you have any questions, please call our office at 215-533-0440.

Unemployment

First Name *

Last Name *

Phone Number *

Email *

Address *

Address 2

City *

State *

Zip Code *

Your full Social Security Number

What is the first date of your claim? *

Did you file for Traditional Unemployment (uses four digit PIN) or PUA (Pandemic Unemployment Assistance, uses self-created user ID/password) *

Are you missing payments? *

Yes

What weeks are you missing? Please list exact dates.

Were you receiving payments and then they stopped? *

Yes

What date did they stop?

Have you checked your payment history? *

Yes

Does it say “pending” or “no payments made”? *

Pending

No Payments Made

Did you quit, get fired or get laid off? *

Quit

Fired

Laid off

Is your claim under review? *

Yes

Not Applicable

Name of employer as it appears on paycheck stub or are you self-employed? *

Has the Department of Labor requested information from you? *

Yes

Have you sent the information requested to the Department of Labor? *

Yes

Please describe your issue: *

If you are human, leave this field blank.

DISTRICT OFFICE

5321 Oxford Avenue
Philadelphia, PA 19124
Phone: (215) 533-0440
Fax: (215) 560-2627
Mon-Fri: 9 a.m. to 5 p.m.

DISTRICT OFFICE

400 W. Allegheny Avenue
Philadelphia, PA 19133
Phone: (215) 291-4653
Fax: (215) 425-5301
Mon-Fri: 9 a.m. to 5 p.m.

HARRISBURG OFFICE

Senate Box 203002
Harrisburg, PA 17120-3002
Phone: (717) 787-1141
Fax: (717) 787-7439
Mon-Fri: 9 a.m. to 5 p.m.

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