Form Ub-126 - Request For Reconsideration/appeal - Arizona Department Of Economic Security
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1UB-126 (10-97)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
REQUEST FOR RECONSIDERATION/APPEAL
Este documento afecta su elegibilidad para Seguro por Desempleo. Si usted no lee inglés, comuníquese con su oficina local o
busque quien le traduzca. La audiencia se conducirá en inglés.
Name and Address of Appellant
In the Matter of the Claim of:
!
!
CLAIMANT’S NAME
SOC. SEC. NO.
EMPLOYER’S NAME
!
!
"
I disagree with the Determination of Deputy dated ____________________________________________ , involving the issue of
______________________________________________________
, and allege it is in error for the following reasons:
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________
"
I also disagree with the Determination of Overpayment dated
created by the above
Determination of Deputy.
If request is not timely, state reason ______________________________________________________________________________
____________________________________________________________________________________________________________
APPELLANT’S SIGNATURE
DATE
NOTICE TO CLAIMANT
If your Request for Reconsideration is denied, and you are still unemployed and wish to claim benefits, you should continue
to file claims pending disposition of your appeal.
COMPLETED BY DEPARTMENT REPRESENTATIVE
REQUEST FILED:
"
In person on __________________________
(Date)
"
By mail postmarked on _________________________________________ (envelope attached)
Received at _________________________________________________________ on _________________________
(Local Office No.)
(Date)
"
"
"
Claimant requests interpreter
Yes __________________________________________
No
Information not available
(Language)
NOTICE TO APPELLANT REGARDING RECONSIDERATION
"
Your request has been reviewed and a reconsidered Determination of Deputy will be issued.
"
Your request for reconsideration has been denied on __________________________ and this action will be forwarded to the
(Date)
Office of Appeals. The specific date and location for your appeal hearing will be provided in a separate communication. The
hearing will be conducted in English (unless you request an interpreter).
BY (Department Representative)
APPROVED (UI Manager)
PAU-174 RESOLUTION CODE ISSUE ID
PROGRAM CODE
Equal Opportunity Employer/Program
This document available in alternative formats by contacting your local office manager.
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