Backdate request 2026

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4.8 out of 5

123 votes

The document is a request form from the Georgia Department of Labor for individuals seeking to backdate their Pandemic Unemployment Assistance (PUA) claims. It requires applicants to provide personal information, specify the desired effective date for their claim, and attach necessary certification forms for previous weeks. The form emphasizes the importance of truthful information and outlines potential penalties for misrepresentation.

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Click ‘Get Form’ to open the backdate request in the editor.
Begin by filling out the Applicant Information section. Enter your first name, middle name, last name, mailing address, and the last four digits of your Social Security Number. Ensure all details are accurate for a smooth processing.
In the Applicant’s Request section, check all applicable boxes. Specify if you are requesting an effective date change or payments for previous weeks. If requesting payments, remember to attach a PUA Weekly Certification Form (DOL-5158PUA) for each week.
Provide a brief explanation for your request in the designated area. This helps clarify your situation to the Georgia Department of Labor.
Finally, sign and date the form electronically. Your electronic signature holds the same validity as a handwritten one, confirming that all information is true and correct.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (123 Votes)

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