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

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APPELLANT: 
LOCAL AMERICAN JOB CENTER
WHERE HEARING WAS HELD (IF KNOWN):
DATE OF ADMINISTRATOR'S DECISION
OR MAIL DATE OF CHARGE NOTICE:

PLEASE DESCRIBE THE DOCUMENT BEING APPEALED. INCLUDE THE FORM NUMBER, IF AVAILABLE:


Employer Information
Employer Registration Number:
Employer Name:
Street:
City:
State: Zip Code: 
Contact Name:
Title:
Telephone Number: (

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

Claimant Information (If Applicable)
Claimant Social Security Number:
Claimant Name:
Street:
City:
State: Zip Code: 

I disagree with the examiner's decision for the following reason(s):


 

If this appeal is not transmitted within 21 days of the decision date or within 21 days of the mail date of the charge notice, whichever is applicable, please explain why:

 


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.


IN SUBMITTING THIS FORM, I HEREBY APPEAL FROM THE EXAMINER'S DECISION TO CHARGE MY MERIT RATING ACCOUNT AND APPLY FOR A HEARING.




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

 

 


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