Uia 1734 Inquiry Form Page 2
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1
2Name: _________________________
__
UIA 1734
(Rev. 11-11)
SSN: ___________________________
Reverse Side
Mail or fax this form to the address or fax number shown below. This form will be returned to you with our answer.
The answer will be written below. If you have any questions, call our Inquiry Line at 1-866-500-0017 (TTY customers
use 1-866-366-0004).
UIA
P. O. Box 169
Grand Rapids, MI 49501-0169
Fax: 1-517-636-0427
RESPONSE
Appropriate question number is circled.
1.
, 2.
, and 3.
Your determination has
has not
been issued because ______________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
4. Payment for the week(s) indicated has not been issued because ___________________________________________________
______________________________________________________________________________________________________
5. Your redetermination has
has not
been issued because _____________________________________________________
______________________________________________________________________________________________________
6. Your hearing has
has not
been scheduled because ________________________________________________________
______________________________________________________________________________________________________
You have not received a decision on your appeal because ________________________________________________________
______________________________________________________________________________________________________
7. You have received no response to your affidavit because_________________________________________________________
______________________________________________________________________________________________________
8. The following is in response to your request: __________________________________________________________________
______________________________________________________________________________________________________
OTHER INFORMATION OR INSTRUCTIONS:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
See Attachment(s).
For UIA Use Only
User ID _____________________________
Date ____/____/____
LARA is an equal opportunity employer/program.
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