unemployment ONLINE aSSISTANCE CENTER
I Missed Filing a Weekly Claim

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IMPORTANT NOTE: 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 stated you missed filing a weekly claim and are trying to contact the TeleBenefits Call Center.  Please complete the form below and include an explanation of the reason why you missed filing your weekly claim.  A representative will work on your request within one business day.

* - Denotes required field

I certify 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.  

* I AGREE
 


* Full Name:   

* SSN       (###-##-####)

* Mother's Maiden Name (for verification purposes):   

* Date of Birth (for verification purposes):       (MM/DD/YYYY)

Email Address: (to contact you only for confirmation)  

Contact Phone    
 


* PLEASE ANSWER THE FOLLOWING QUESTIONS:
 

PRESENT WEEK (today's "present week" is defined as Sunday, June 11, 2017 through Saturday, June 17, 2017) MISSED WEEK (this is the week you missed prior to the "present week" entered at left)
Were you able to work, available for work, and actively
seeking full-time employment?  
Yes    No

Have you previously reported that you are only available
for part-time work because of a physical or mental impairment? 
Yes    No

Did you refuse an offer of work or rehire, quit a job or get discharged from a job?  Yes    No

Did you receive your first payment from a pension other than Social Security, or was there a change in the amount previously reported?    Yes    No

Did you start school, college, or training which you have not already reported to the Labor Department? Yes  No

Did you receive vacation pay, severance pay or workers compensation benefits, not previously reported to the Labor Department?  Yes    No

Did you work for an employer or in self-employment?
 
Yes    No

  • If yes, how many employers?   
    (
    If there is more than one employer, a representative
    will contact you.)

  • Did you start working full-time, including self-employment?  Yes    No

 
  • Name of employer that you worked for during this period (enter the word "self" if self-employed):

     
  • Address of employer that you worked for during this period (enter the word "self" if self-employed):
     
  • Number of hours you worked (including self employment): 
     
  • Total gross (before taxes are deducted) earnings (including self employment): 

Have you changed your mailing address since you last filed a claim?  If yes, click here to complete the Address Change Form. Yes   No


I certify that I have answered the above questions
truthfully and understand that giving false information or answering questions for anyone other than myself constitutes FRAUD and is punishable by law. 
 * Yes

* Please provide an explanation of why you missed filing your weekly claim:

 

Were you able to work, available for work, and actively
seeking full-time employment?  
Yes    No

Have you previously reported that you are only available
for part-time work because of a physical or mental impairment? 
Yes    No

Did you refuse an offer of work or rehire, quit a job or get discharged from a job?  Yes    No

Did you receive your first payment from a pension other than Social Security, or was there a change in the amount previously reported?    Yes    No

Did you start school, college, or training which you have not already reported to the Labor Department? Yes  No

Did you receive vacation pay, severance pay or workers compensation benefits, not previously reported to the Labor Department?  Yes    No

Did you work for an employer or in self-employment?
 
Yes    No

  • If yes, how many employers?   
    (
    If there is more than one employer, a representative
    will contact you.)
  • Did you start working full-time, including
    self-employment? 
    Yes    No
 
  • Name of employer that you worked for during this period (enter the word "self" if self-employed):

     
  • Address of employer that you worked for during this period (enter the word "self" if self-employed):
     
  • Number of hours you worked (including self employment): 
     
  • Total gross (before taxes are deducted) earnings (including self employment): 

Have you changed your mailing address since you last filed a claim?  If yes, click here to complete the Address Change Form. Yes  No


I certify that I have answered the above questions
truthfully and understand that giving false information or answering questions for anyone other than myself constitutes FRAUD and is punishable by law. 
 * Yes

* Please provide an explanation of why you missed filing your weekly claim:

 

    

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