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SAMPLE, this page for reference only.
Your correspondence postmarked/received MM/DD/YYYY regarding a recent decision of the Department is acknowledged. The decision has been carefully reviewed and appears to be correct. An appeal has been processed and forwarded to the XXXX Office of Appeals, telephone number 000-000-0000.
Unemployment Insurance (UI) benefit claim forms for the week(s) ending MM/DD/YYYY are being mailed in a separate envelope. You have the right to receive UI benefits pending your appeal. Even if you do not wish to receive UI benefits, you should continue to certify for benefits for each week of unemployment until you receive the Administrative Law Judge’s decision.
If you choose to receive UI benefits pending the appeal hearing, the Department will pay those UI benefits if you are otherwise eligible. If the judge affirms the Department’s determination, you may have to repay any UI benefits you receive.
If you choose not to receive UI benefits pending the appeal hearing, and if the judge reverses the Department’s determination decision and finds that you are eligible, you will be paid UI benefits only for those weeks for which you have submitted a claim form and met all other eligibility requirements.
The Office of Appeals will send you a notice showing the date, time, and place of your hearing. You should make every effort to attend the hearing since the Judge will base his/her decision on the oral and written evidence at the hearing. During the hearing, you will be allowed to explain the facts and to present evidence in support of your case.
Please indicate your decision below by checking the appropriate box. You must sign, date and return this form.
WHEN YOU HAVE COMPLETED AND SIGNED THIS FORM, RETURN IT TO OUR OFFICE IMMEDIATELY IN THE ENCLOSED ENVELOPE.