Claimant Information 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 Timeliness Declaration 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. 1. Did you receive the Determination Letter under appeal? Yes No 2. When did you receive the Determination Letter? 3. How did you receive the Determination Letter (eServices, Postal Mail)? 4. Did you read and understand the Determination Letter under appeal? Yes No If No, please explain: 5. Why didn’t you file an appeal by the deadline? 6. Why are you appealing now? Provide any additional information that you would like the judge to consider: 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
