Claimant Name First Name Last Name Address Street Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code Email Phone 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 following 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 the same questions before. Work Searches 1. Did you look for work during the week(s) indicated in the Determination Letter? Yes No 2. Are you a member of a Union? Yes No Name of Union Are you a member in good standing? Yes No Were you available for dispatch during the weeks claimed? Yes No 3. If you looked for work, how many employers did you contact each week? 4. Did you do any alternate work search activities to look for work? For example, attending WorkSource appointments or job fairs, updating a resume, or creating a profile on a job search or networking web site? Describe your other work search activities: 5. Did you engage in at least three work search activities (including employer contacts) each week? Yes No 6. Were you employed during the week(s) indicated in the Determination Letter? Yes No Name of employer: Dates of employment: 7. Did you accept an offer of work, during the week(s) indicated in the Determination Letter? Yes No Name of employer: What date was the offer of employment made? What date did the new employer offer for you to start work? What date did you start work with the new employer? Provide a copy of your written offer of work, if there was one. Documents can be provided by mail, fax, or through OAH’s participant portal. 8. Are you employed, but temporarily stopped working? Yes No If yes, why did you stop working? When did you stop working? When did you or do you expect to resume work for your employer? When did you or do you expect to resume work for your employer? 9. Are you participating in full time training, with written approval of the Employment Security Department? Yes No If yes, provide a copy of your Commissioner Approved Training (CAT) Determination Letter. Documents can be provided by mail, fax, or through OAH’s participant portal. 10. Are you looking for full time work (at least 35 hours per week)? Yes No I am available to work (number of hours) per week. 11. What type of work do you normally do? 12. What type of work are you seeking? 13. Did you search for work in fields in which you have experience or training? Yes No Explain why not: 14. Did you keep a record of your job search activity? Yes No If yes, provide a copy of your job search logs and any additional documentation you have, such as emails or job announcements. Documents can be provided by mail, fax, or through OAH’s participant portal. If no, provide a copy of your written statement with as much information as possible about your job search activities. Include copies of any documentation you have, such as emails or job announcements. Documents can be provided by mail, fax, or through OAH’s participant portal. 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 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
