Declaration of (Name) First Name Last Name Docket Number(s) I am (age) years old I am the (check one) Claimant Other (relationship to the people in this case) Name and relation to claimant 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. Fault 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 If no, please give details about why you did not provide the requested information. 2. Was the information you provided completely accurate? Yes No If no, please give details about why the information was not 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? Yes No If yes, please give details about what that information was and why you responded as you did. 4. Did you leave out any information that was requested by the Department when you filed your claim for benefits? Yes No If yes, please give details about what that information was. 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 If yes, please explain in detail starting with the date. 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 If yes, please explain in detail why the information was different. 7. Is there any additional information you would like judge to considered regarding whether you are at fault for the overpayment? Yes No If yes, please describe what that additional information is. Waiver Your Household: 1. How many people live with you? 2. Are any of these people minor children who depend on you for support? Yes No If yes, indicate number and ages of dependent children in your household: 3. Do you pay child support for minor children who do not live in your household? Yes No If yes, indicate your monthly child support expenses: 4. Are you married? Yes No If yes, does your spouse’s income help pay for household expenses (rent/mortgage, power, food, etc.)? Yes No If yes, how much does your spouse contribute per month? 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.)? Yes No If yes, how much do these household members contribute per month? Expenses - Please answer $0 for all those that do not apply. 1. What is your share of your monthly housing payment, either rent or mortgage? 2. How much are your average monthly expenses for utilities (gas, power, water/trash)? 3. If you have a car payment, how much are you required to pay each month? 4. How much do you pay per month in car insurance? 5. How much do you pay per month for telephone service? 6. How much do you pay per month for internet service? 7. How much do you pay per month for food? 8. How much do you pay per month for gasoline for your vehicle(s)? 9. Please list any other required monthly expenses not listed above. Assets 1. Are you currently working? Yes No If yes, when did you start working? If yes, what is your monthly gross income from employment (before taxes)? 2. If you are married, is your spouse currently working? Yes No N/A If yes, when did your spouse start working? If yes, what is your spouse’s monthly gross income? 3. Are you currently receiving unemployment benefits? Yes No If yes, what is your weekly benefit amount? 4. What is the total balance of your checking account(s) as of the date you are completing this form? 5. What is the total balance of your savings 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? 7. Do you have any other source of income besides employment (alimony, social security, VA benefits, etc.)? Yes No If yes, please describe the additional income, and how much on average you earn or receive per month. 8. Do you have any other assets (property, stocks, annuities, trusts, etc.) not identified above? Yes No If yes, please list what they are and how much they are worth. 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)? Yes No If yes, please describe how it would deprive you of basic living necessities. 2. Is there any additional information you would like judge to considered regarding whether waiver should be applied to your overpayment? Yes No If yes, please describe what that additional information is. 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 Leave this field blank
