BAP Availability and Overpayment

Declaration of (Name)

First Name
Last Name

I am (age) years old

Name and relation to claimant

Availability

1.Did you suffer from any sicknesses or injuries which kept you from working full time?

Yes

No

2. Did you have adequate transportation to look for and get to work?

Yes

No

3. Do you care for anyone else (minor child, sick spouse, elder parent) that would keep you from performing full time work?

Yes

No

When did that care begin?

4. Were you a full time student during this period?

Yes

No

What was your academic schedule?

What are the hours of your customary profession?

Would you be willing to drop your classes to accept full time work if the offered work conflicted with your academic schedule?

Yes

No

If requested, could you provide a list of those job searches?

Yes

No

Employer:

7. Were there any other reasons you were not able or available for full time work?

Yes

No

Overpayments

2. Did you provide all the information requested by the ESD in its investigation about the issue which caused the overpayment?

Yes

No

3. Was the information you provided completely accurate?

Yes

No

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

5. Did you leave out any information that was requested by ESD when you filed your claim for benefits?

Yes

No

6. Did you later discover, or did ESD bring to your attention later, that you had not provided accurate or complete information?

Yes

No

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

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 include any additional information you wish the judge to know about this case: