Form Ucb-474 - Medical Report To Determine Unemployment Insurance (Ui) Eligibility (Page 6 of 6) in pdf

Form Ucb-474 - Medical Report To Determine Unemployment Insurance (Ui) Eligibility Page 6

State of Wisconsin

Department of Workforce Development

Unemployment Insurance Division

CLAIMANT

THIS IS A

EMPLOYER APPEAL TO THE DETERMINATION

(If you disagree with a Computation or a Letter of Direction,

follow the instructions on that document.)

Before completing this form, read both sides of the DETERMINATION.

Claimant’s Name [Please print]:

Claimant’s Social Security Number: __ __ __ - __ __ - __ __ __ __

ID: __ __ __ __ __ __ __ __ __ (9-digit number on the DETERMINATION. A copy of the

determination must be included with this form.)

The work was performed at:

Employer’s Name:

Address:

City:

State: ______ ZIP:

Explain why you disagree with the DETERMINATION. Also, if your appeal is late, explain why.

Continued on reverse side.

Provide your attorney or agent’s name and address (if you are represented), dates of unavailability for a hearing, or any

special needs you may require.

Review this document to make sure you have provided all the information, including marking

whether this is a claimant or an employer appeal.

Signed:

Date:

Send this form to the hearing office listed on the back of the DETERMINATION.

Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)].

3.32

April 2000

Form Ucb-474 - Medical Report To Determine Unemployment Insurance (Ui) Eligibility Page 6