BAP Overpayment Declaration

Declaration of (Name)
I am the (check one)

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?
2. Was the information you provided completely accurate?
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?
4. Did you leave out any information that was requested by the Department when you filed your claim for benefits?
5. Did you later discover, or did the Department bring to your attention later, that you had not provided accurate or complete information?
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?
7. Is there any additional information you would like judge to considered regarding whether you are at fault for the overpayment?

Your Household:

2. Are any of these people minor children who depend on you for support?
3. Do you pay child support for minor children who do not live in your household?
4. Are you married?
If yes, does your spouse’s income help pay for household expenses (rent/mortgage, power, food, etc.)?
5. Do any other members of your household (i.e., roommate(s) or other adults living with you) help pay for household expenses (rent/mortgage, power, food, etc.)?

Expenses - Please answer $0 for all those that do not apply.


1. Are you currently working?
2. If you are married, is your spouse currently working?
3. Are you currently receiving unemployment benefits?
7. Do you have any other source of income besides employment (alimony, social security, VA benefits, etc.)?
8. Do you have any other assets (property, stocks, annuities, trusts, etc.) not identified above?

Equity and Good Conscience

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