Office of Administrative Hearing Appeal Form

Office of Administrative Hearings Appeal Form

Complete and submit this form to request an appeal of a Notice of Redetermination issued by the Unemployment Insurance Division.

In 3-5 business days, you will receive a packet in the mail from the Office of Administrative Hearings with the date of your hearing and your case information.

Party Requesting Appeal

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Claimant Information

Claimant Name*

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ID*

Must be a valid Claimant ID

Last 4 digits of Claimant’s SSN*

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Employer Information

Employer/Business Name*

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Employer ID*

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Phone Number*

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Email*

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Appeal Details

Notice of Redetermination Date*

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Issue Number*

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Reason(s) for Appeal Request (maximum 750 characters)*

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Office of Administrative Hearings Appeal Form

Claimant Information

Employer Information

Appeal Details