EXTREMELY IMPORTANT NOTE REGARDING THE ENTRY OF
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Before submitting this form please verify that all required information is
fully completed and that all information matches what you would have
provided to the Department of Labor when you originally filed your claim.
You have indicated you did not
receive your payment.
Please complete the form below.
* - Denotes
that I am the claimant indicated below. I understand that the law
provides penalties for making false statements or any
misrepresentation to obtain unemployment benefits.
* Full Name:
* Mother's Maiden Name (for
* Date of Birth (for
Email Address: (to contact you
only for confirmation)
Contact Phone (including area code):
* Please check
all that apply:
System would not allow me to file.
I was out of the country from
I was out of the state from
I failed to file the prior week and the system told me to
speak to a customer service representative.
No work was offered by my employer during the week of
I work as an “as needed basis” or per diem,
i.e., work on work off.
I was not physically able to work due to medical reasons.
I was not available for all hours schedule during the week of
I answered the weekly continue claim questions incorrectly.
I received severance and vacation pay:
I received a pension.
I was trying to enter my earnings and the system will not take it.
My gross earnings are: $
My benefits are on hold.
Bank account information updated - please reissue my