Petition Form For Appeal
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1
2PETITION FOR APPEAL
UC-46B REV 6-05
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF LABOR AND INDUSTRY
UNEMPLOYMENT COMPENSATION
UC BENEFIT PROGRAM
BOARD OF REVIEW
SEE ADDITIONAL INFORMATION ON REVERSE
IMPORTANT! – READ THE INFORMATION ON THE REVERSE OF THIS FORM BEFORE FILING AN APPEAL.
If you want to appeal the enclosed notice of determination, complete Section 1 below and return this form in
accordance with the appeal instructions on the determination. To be timely, an appeal must be filed by the last
date to appeal as indicated on the determination.
FOLLOW THE APPEAL INSTRUCTIONS CAREFULLY.
SECTION I: TO BE COMPLETED BY PERSON FILING APPEAL
_______________________
CLAIMANT’S NAME AND ADDRESS:
DATE OF DETERMINATION BEING APPEALED:
. _______________________________
CLAIMANT’S SOCIAL SECURITY NO
. _____________________________________
CLAIMANT’S TELEPHONE NO
WORK ADDRESS OF THE EMPLOYER INVOLVED IN THE APPEAL:
Employer’s telephone no. (
)
-
:
REASONS FOR DISAGREEING WITH THE DETERMINATION AND FILING THIS APPEAL ARE
NAME OF PERSON FILING APPEAL
ADDRESS OF PERSON FILING APPEAL
SECTION II: TO BE COMPLETED ONLY BY THE UC SERVICE CENTER
_______________________________
APPEAL NO
.
_______________________________
on
APPEAL FILED BY:
CLAIMANT
EMPLOYER
EMPLOYMENT SECURITY
APPEAL RECEIVED BY:
UCSC
PA CAREERLINK
PERSONALLY DELIVERED
__________________
POSTMARKED
FAXED
______
____________
. __________________
TYPE CLAIM:
UC
UCFE
UCX
EB
DUA
TRA
OTHER
TRADE ACT PETITION NO.
NAFTA PETITION NO
APPELLANT REQUIRES ASSISTANCE:
BECAUSE OF DISABILITY WITH
HEARING
SPEECH
VISION
FOR THE FOLLOWING SPOKEN LANGUAGE _____________________________
OTHER __________________________________________________________________
________________________________________
________________________________________________
ELIGIBLE SECTION(S) :
INELIGIBLE SECTION(S):
APPLICATION FOR BENEFITS DATE _______________________________ CLAIM WEEK(S) RULED ON ___________________________________________________________________
____________________________________________
UC SERVICE CENTER:
SIGNATURE OF APPEAL CLERK
NAME AND ADDRESS OF EMPLOYER(S) AND ANY OTHER PARTY INVOLVED IN THE CLAIMANT’S ELIGIBILITY:
EMPLOYER’S ADDRESS
EMPLOYER’S REPRESENTATIVE (if any)
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