Weekly Filing Issue

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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.

The purpose of this form is to resolve any issues with your weekly filing. If you made a mistake while completing your weekly claim, or were advised to use this link please complete the form below and include an explanation of any answer that requires us to get further information. We will need further information if you answer No to question 1 or Yes to questions 2-7.  A representative will work on your request, it may take up to three business days.

* - 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       (###-##-####)

* 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    


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

1a. Have you previously reported that you are only available
for part-time work because of a physical or mental impairment? 
Yes    No

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

3. 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

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

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

6. 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): 

7. 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

* You must provide an explanation for why you are filling out this form. If you are an on call employee please give us more information or if you answered No to question 1 or Yes to questions 2-7 please provide an additional explanation below(ex: reason you are not available, employer you refused work from or quit, details of pension, schooling, or severance etc.) :



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