BAP Overpayment

Docket Number(s)

I am the (check one)

Claimant

Other (relationship to the people in this case)

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.

1. Did you provide all the information requested by the Employment Security Department (“ESD”) in its investigation about the issue that caused the overpayment?

Yes

No

2. Was the information you provided completely accurate?

Yes

No

3. Did you provide any information to the Department about which you were not entirely sure or didn’t fully know the answer at the time?

Yes

No

4. Did you leave out any information that was requested by the Department when you filed your claim for benefits?

Yes

No

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

Yes

No

6.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

7. Is there any additional information you would like judge to considered regarding whether you are at fault for the overpayment?

Yes

No

Waiver

Your Household:

2.Are any of these people minor children who depend on you for support?

Yes

No

3.Do you pay child support for minor children who do not live in your household?

Yes

No

4. Are you married?

Yes

No

If yes, how much does your spouse contribute per month?

If yes, how much do these household members contribute per month?

1. What is your share of your monthly housing payment, either rent or mortgage?

3.If you have a car payment, how much are you required to pay each month?

5. How much do you pay per month for telephone service?

7. How much do you pay per month for food?

9. Please list any other required monthly expenses not listed above.

1. Are you currently working?

Yes

No

If yes, what is your monthly gross income from employment (before taxes)?

If yes, when did your spouse start working?

3. Are you currently receiving unemployment benefits?

Yes

No

4. What is the total balance of your checking account(s) as of the date you are completing this form?

6. If you have a retirement account(s), how much is in the account(s) as of the date you are completing this form?

If yes, please describe the additional income, and how much on average you earn or receive per month.

If yes, please list what they are and how much they are worth.

1.If you were required to repay the overpayment listed in the determination, would it deprive you of basic living necessities (i.e., food, shelter, or access to medical care)?

Yes

No

2. Is there any additional information you would like judge to considered regarding whether waiver should be applied to your overpayment?

Yes

No

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.

Washington State
Office of Administrative Hearings

Overpayment Declaration