I did not receive my benefit payment

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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 have indicated you did not receive your payment.  Please complete the form below.

* - 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. 


* Full Name  

* SSN     (format = ######### - no dashes please)

* 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 (including area code)    

* Please check all that apply:

  System would not allow me to file.

  I was out of the country from   to 

  I was out of the state from   to 

  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:

  • severance pay: $   hours

  • vacation pay: $   hours

  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 payment(s)


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