Brief Adjudicative Proceeding Work Search and Overpayment Declaration

Claimant Name
Address
I am the (check one)

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?
2. Are you a member of a Union?
Are you a member in good standing?
Were you available for dispatch during the weeks claimed?
5. Did you engage in at least three work search activities (including employer contacts) each week?
6. Were you employed during the week(s) indicated in the Determination Letter?
7. Did you accept an offer of work, during the week(s) indicated in the Determination Letter?

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?
9. Are you participating in full time training, with written approval of the Employment Security Department?

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)?
13. Did you search for work in fields in which you have experience or training?
14. Did you keep a record of your job search activity?

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.

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?
2. Did you provide all the information requested by ESD in its investigation about the issue which caused the overpayment?
3. Was the information you provided 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?
5. Did you leave out any information that was requested by ESD when you filed your claim for benefits?
6. Did you later discover, or did ESD bring to your attention later, that you had not provided accurate or complete information?
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?
8. Is there any additional information you would like the judge to consider regarding whether you are at fault for the overpayment?

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.