STATEMENT OF BENEFITS

TEXAS WORKFORCE COMMISSION

PO BOX 149137
AUSTIN TX 78714-9137
Statement of Wages and Potential Benefit Amounts
Disaster Unemployment Assistance (DUA)
Date Mailed: June 22, 2020
(All dates are in month/day/year order)

JOSE A SANCHEZ
2901 W HWY 83 LOT 75
MCALLEN TX 78501

Social Security Number: XXX-XX-4827

Recalculation of Benefits

Dear JOSE A SANCHEZ

According to our records, you earned the wages/net income below in the 2019 tax year. We use
these wages to calculate the weekly amount of Disaster Unemployment Assistance (DUA) benefits you
could receive if you are eligible and meet the weekly requirements.
Double-check this wage information with your records! Call TWC immediately at 1-800-939-6631 if
the employer name or the wage amount is incorrect, or if any wages are missing or wrong. You can
request a review any time until the end of the disaster assistance period. The disaster assistance period
begins 03-01-20 and ends 12-26-20.

Based on the wages listed in the box below*, your DUA weekly benefit amount is $ 385. The
maximum weekly benefit amount for this disaster is $ 521. The minimum weekly benefit amount
for this disaster is $ 207.

EMPLOYER NAME ST YOUR CLAIM IS BASED ON THESE WAGES TOTALS

Jan-Mar 2019 Apr-Jun 2019 Jul-Sep 2019 Oct-Dec 2019
TELEPERFORMANCE USA TX 0.00 0.00 0.00 2,326.66 2,326.66
CHARTER COMMUNICATIONS LLC TX 9,626.14 7,363.44 4,629.40 18.11 21,637.09

TOTALS $9,626.14 $7,363.44 $4,629.40 $2,344.77 $23,963.75

* No wages listed? We will only use wages or net income from the 2019 tax year if we receive
acceptable proof from you before the disaster assistance period ends-otherwise you are only entitled to
the minimum DUA amount.

. Proof of wages for workers: pay stubs, earnings statements, IRS Form W-2 and/or IRS Form 1099
. Proof of wages for self-employed individuals: IRS Form 1040 and a copy of Schedule C, F, or SE
return
. If you did not work during the 2019 tax year, read the back of this form.

Mail or fax copies of your proof documents to: Texas Workforce Commission, Attn: DUA Wages and
Income, 101 E. 15th Street, Room 354, Austin, Texas, 78778; FAX: (512) 936-3250. Write your name
and Social Security Number on every document you submit to TWC.

Claim ID.: 4485

TWC Telephone No.: (800)939-6631
FOR HEARING IMPAIRED CLIENTS
Relay Texas TDD No.: 1-800-735-2989
Voice No.: 1-800-735-2988

BM105E 12/09/09
 Qualifying Base Period Your DUA claim base period is the most recently completed tax year
(January 1st through December 31st). DUA claims use a different base
period than regular claims.
Income Taxes DUA benefits are taxable. You may withhold income tax from your
benefits payments. TWC will send you IRS Form 1099-G next January
with the total amount of benefits you received.
Penalties TWC regularly audits unemployment claims. If you report incorrect
information or withhold information on any claim, you must repay
benefits TWC paid to you and give up your right to future benefits.
Penalties may include fines and/or imprisonment.

How we calculate your weekly benefit amount

. To determine your weekly benefit amount (WBA), we select the base period quarter with the
highest wages, divide that number by 25, and round to the nearest dollar. Your WBA cannot
exceed the maximum amount set by law. You must have wages in at least two base period
quarters and wages totaling at least 37 times your WBA.
. If you do not have any wages/income or insufficient wages/income to qualify for up to 50
percent of the state average WBA, you will be entitled to 50 percent of the state average WBA,
which is the minimum DUA WBA payable under the disaster.
. If you worked part-time prior to the disaster, we will adjust your WBA in proportion to the
number of hours you worked per week and the customary full-time hours for your occupation.
. If you worked in a family unit or business, TWC will assign wages/net income equally to the
adult family members of the business unless you submit documentation to assign wages differently.
TWC will use actual wages earned for minors working in the family unit or business.
. DUA claims do not have a fixed maximum benefit amount. TWC can only pay DUA benefits if
your unemployment is a direct result of the disaster or until the end of disaster assistance
period, whichever comes first.
. Visit www.texasworkforce.org/dua for more information.

Appeal Rights: If you requested a review of your wages, and still disagree with the reported amounts,
you may appeal. You must mail or fax your appeal no later than 60 days from the date TWC mailed this
form. Mail or fax your appeal in writing to TWC Appeals Department, 101 E 15th Street, Austin, Texas,
78778; FAX: (512) 475-1135. Please write your Social Security Number on the appeal and include a copy
of this form. TWC will use the postmark (if mailed) or the date we receive the fax to determine
whether your appeal is timely. Keep your fax confirmation as proof of transmission. Continue to file
your DUA payment requests while the appeal is pending. If the appeal decision is in your favor, TWC
can only pay you for weeks in which you requested payment and met all other requirements. For more
information about the appeal process, please visit www.texasworkforce.org/ui/appl/claimants_intro.html.

Law Reference: Title 20 Code of Federal Regulations Part 625.6 (20 CFR 625.6)

BM105F 12/02/09
 Texas Workforce Commission
DUA Proof of Employment Cover Sheet

Please complete and return this form with your proof of employment and wages.

Send TWC proof of employment, self-employment, or prospective employment within 21

DAYS from the date you filed your DUA claim or your benefits will stop. Proof of
employment documents should support that you were employed or self-employed at the time
the disaster occurred, be recent and dated just prior to the date of the disaster. Proof of
wages documents should verify the amount of income you earned in the 2019 tax year.
Review your DUA Statement of Benefits to see the wages TWC already has on file.
Send copies only - TWC will not return documents.

Name__________________________________ SSN________________________ Number of Pages____

For Workers, Employees, or Contract Laborers

Proof of employment - Choose ONE. Check the box next to the type of proof you are sending.

Recent pay stub or voucher issued just prior to the disaster

Recent earnings statement
Written statement from your employer OR a notarized statement from a coworker
A letter from your potential employer (you were going to start work on or after the date of the disaster)

AND

Proof of wages and principal source of income for the 2019 tax year - Check all that apply.
If the DUA Statement of Benefits shows all of your wages, you do NOT need to send proof.
Pay stubs or vouchers from the 2019 tax year (at least 3)
Earnings statements from the 2019 tax year (with year to date earnings)
IRS Form W-2
IRS Form 1099 for non-wage income

For Self-Employed Individuals

Proof of self-employment - Choose ONE. Check the box next to the type of proof you are sending.

Recent business bank records, phone, utility, or insurance bill, sales tax return, business license, State or
Federal Employer Identification Number
Recent newspaper/phone book ad for your business
Property titles, deeds, or rental agreement for the place of business
A letter or rental agreement showing you were going to open a business on or after the date of the
disaster

AND

Proof of wages and principal source of income - Send the following forms.
Federal income tax Form 1040 AND Schedule C, F, or SE tax returns for the 2019 tax year

Fax or mail copies of proof to: Texas Workforce Commission

Attn: DUA Proof
FAX: (512) 936-3250 101 E. 15th Street, Room 354
Austin, Texas 78778

For more information visit www.texasworkforce.org/dua

BM107E 01/27/10