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Appeals


 

This form may be used to file an appeal. Please provide complete information. Failure to do so may require contacting you, which delays processing the request. Please do NOT include the claimant's full Social Security Number.


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1.   Appeal requested by    (Select one) **Required
  Claimant    Employer   
 
2.   Enter Claimant's name:    (Type Answer) **Required
 
(50 character limit; 50 remaining.)
 
3.   Enter the last four digits of the Claimant's Social Security Number:    (Type Answer) **Required
 
(4 character limit; 4 remaining.)
 
4.   IF EMPLOYER APPEAL, enter business name; agent name (if applicable); name/job title of person filing the appeal:    (Type Answer)
 
(200 character limit; 200 remaining.)
 
5.   Enter your email address:    (Type Answer)
 
(50 character limit; 50 remaining.)
 
6.   Enter your telephone number, including area code (Example: 999-111-0000) **Required
  Ext:
 
7.   Do you need an interpreter?    (Select one)
  Yes    No   
 
8.   IF "Yes", enter the language needed:    (Type Answer)
 
(50 character limit; 50 remaining.)
 
9.   Enter the determination's "Date Issued" - Found on the determination's right side, near the top:    (Type Answer) **Required
 
(20 character limit; 20 remaining.)
 
10.   10. Enter Determination Identification Number, Docket, or Employer account number:    (Type Answer) **Required
 
(9 character limit; 9 remaining.)
 
11.   Provide every reason why you disagree:    (Type Answer) **Required
 
(500 character limit; 500 remaining.)
 
12.   Do you have additional Information you would like to provide? (IF “Yes”, please make sure to provide contact information in your answer to questions 5 and 6)    (Select one)
  Yes    No   
 
13.   If it is more than 14 days after the date issued, give the reason why the request is filed late:    (Type Answer)
 
(500 character limit; 500 remaining.)
 

CLAIMANT: Continue to file claims for each week of unemployment during the appeal process, as benefits may only be paid for weeks claimed timely.

 
 
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