Declaration of (Name) First Name Last Name Docket Number(s) I am (age) years old I am the (check one) Claimant Other (relationship to the people in this case) Name and relation to claimant Please answer all of the questions. Some of the questions may have been asked during the Employment Security Department’s investigation. Please answer the questions here, even if you answered them before. Availability The following questions are about the period you were unemployed or partially unemployed (in other words, the period you are requesting benefits for). 1. Did you suffer from any sicknesses or injuries which kept you from working full time? Yes No Please give details about (i) your sickness and/or injuries, and (ii) when or if you have recovered enough to perform full time work. 2. Did you have adequate transportation to look for and get to work? Yes No Please give details about (i) your transportation problems, and (ii) when or if those transportation problems got resolved. 3. Do you care for anyone else (minor child, sick spouse, elder parent) that would keep you from performing full time work? Yes No Who were you caring for? When did that care begin? Are you still caring for them? 4. Were you a full time student during this period? Yes No What type of academic program were you enrolled in? What was your academic schedule? What is your customary profession? What are the hours of your customary profession? 5. Did you perform at least the minimum required work searches for each of the weeks you have been requesting benefits, starting the week of July 4, 2021? Yes No If requested, could you provide a list of those job searches? Yes No 6. If you did not look for work, do you have a job offer with a definite start date? Yes No Employer: Start date: 7. Were there any other reasons you were not able or available for full time work? Yes No Please describe what those reasons are in detail. Overpayments 1. Did the Employment Security Department (“ESD”) give you notice that any of the benefits listed in the appealed Determination Letter were paid conditionally? Yes No 2. Did you provide all the information requested by the ESD in its investigation about the issue which caused the overpayment? Yes No Please give details about why you did not provide the requested information. 3. Was the information you provided completely accurate? Yes No Please give details about why the information was not completely accurate. 4. Did you provide any information to ESD about which you were not entirely sure or didn’t fully know the answer at the time? Yes No Please give details about what that information was and why you responded as you did. 5. Did you leave out any information that was requested by ESD when you filed your claim for benefits? Yes No Please give details about what that information was. 6. Did you later discover, or did ESD bring to your attention later, that you had not provided accurate or complete information? Yes No Please explain in detail starting with the date. 7. Was there a difference in what you told ESD during the investigation and what you stated in your appeal, or during a hearing. For example, you told ESD you were not available for full time work, but stated in your appeal that you were available for full time work? Yes No Please explain in detail why the information was different. 8. Is there any additional information you would like the judge to consider regarding whether you are at fault for the overpayment? Yes No Please describe what that additional information is. Please include any additional information you wish the judge to know about this case: I declare under penalty of perjury under the laws of the state of Washington that the facts I have provided on this form are true. I agree. Submit Leave this field blank
