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Claimant's Appeal To Referee
CLAIMANT'S APPEAL TO REFEREE State of Connecticut
Department of Labor
Employment Security Appeals Division

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Please Note the following:
  • We have found that problems may occur with this page when using a mobile device. We recommend filing your appeal from a desktop or laptop computer.
  • Please do not use special characters such as "é" and "â" (for example in words such as "café" or "fiancé", and in some proper names as well) when entering your appeal; we have found that these characters can cause the appeal to be dropped by the system.
  • Please also do not paste text into the text boxes as we've found that problems can be caused by doing this as well.

Appellant:  Claimant

MAILING DATE OF DECISION LETTER:

Claimant Information
Claimant Social Security Number:
Claimant Name:
Street:
City:
State:   Zip Code: 
Telephone Number:   -  
If you need an interpreter for the hearing, which language?

Claimant Agent Information (If Applicable)
Claimant Agent Name:
Street:
City:
State:   Zip Code: 

Employer Information (If Applicable)
Employer Registration Number:
Employer Name:
Street:
City:
State:   Zip Code: 

Please do not paste text or enter "special characters" into the text boxes.

I disagree with the examiner's decision for the following reason(s). (If you received more than one decision, please indicate which decision(s) you are appealing.)


 

If this appeal is not submitted within 21 days of the decision date, please explain why:


IMPORTANT:
CLAIMANT - CONTINUE TO FILE: Please check the box below to acknowledge that you understand that you must continue to file claims pending a decision by the Referee on your appeal. If you fail to file a claim each week, as directed, no benefits can be paid for those weeks, irrespective of the decision of the Referee.


IMPORTANT:

PLEASE BE SURE TO PRINT A COPY OF THE DATA CONFIRMATION PAGE THAT WILL DISPLAY AFTER YOU SUBMIT THIS FORM. KEEP THIS COPY FOR YOUR RECORDS. YOUR COPY OF THE DATA CONFIRMATION PAGE VERIFIES THAT YOUR APPEAL HAS BEEN FILED AND RECEIVED FOR PROCESSING BY YOUR LOCAL AMERICAN JOB CENTER.


IN SUBMITTING THIS FORM, I HEREBY APPEAL FROM THE LOCAL AMERICAN JOB CENTER DECISION DENYING BENEFITS AND APPLY FOR A HEARING.




Please refer to A Claimant's Guide to the Appeals Process for more information about the unemployment compensation appeals process.

 

 


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