EXTREMELY IMPORTANT NOTE REGARDING THE ENTRY OF
The form below requires confidential information. Therefore, it is
vital for you to close your browser completely after
submitting this form. This will prevent others from accessing the
information you have entered. To close your browser, click the "x" in
the top right-hand corner of the browser window.
IMPORTANT NOTE: Verify you completed the
form and all information is accurate
and matches your filed claim before you submit it.
You have accessed this page because you received a
letter stating that you accessed or changed your unemployment
benefits payment method or your address and you are certifying that
you did not authorize this change.
* - 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:
(format = ######### - no dashes please)
* Mother's Maiden Name (for
* Date of Birth (for
Email Address: (to contact you
only for confirmation)
Based on the letter I received, I am reporting that (select one only):
I did not access or change my unemployment payment benefits method
I did not change my address on my unemployment claim