Form B-14 - Employer Appeal Form - Unemployment Insurance - Vermont Department Of Labor - 2017

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Employer Appeal Form
Unemployment Insurance
Employer Name:
Employer Account Number:
Address:
City/State/Zip:
Phone Number:
Email Address:
 Contribution Rate
 Assessment
Appeal Determination of:
 Liability/ABC Test
 Claim for Unemployment Insurance Benefits
Date of Determination: __________________________
Reason for appeal:
If this Appeal is for unemployment insurance benefits, you MUST include the claimant’s name and last 4 digits of the Social
Security Number.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Signature: __________________________________________
Date: _________________
Printed Name: _____________________________________
You may submit your Appeal:
•
By email to labor.appeals@vermont.gov
•
By fax to the Appeals Unit at (802) 828-4289
•
By U.S. mail: Appeals, Vermont Department of Labor, PO Box 488, Montpelier, VT 05601-0488
•
In person at the administrative offices of the Vermont Department of Labor, 5 Green Mountain
Drive, Montpelier, VT 05601
The postmark date of a mailed appeal, the email date of an emailed appeal, and the fax date of a faxed appeal will be
considered the filing date for those respective submission types. An appeal filed in person will be date stamped by the person
receiving the appeal, and the date stamped will be considered the filing date. Please include the name and date of the
document(s) being appealed. Once your request for an appeal has been processed, you will be notified in writing of the date
and time of a scheduled hearing. Additional information and assistance about filing an appeal is available at labor.vermont.gov
or by calling the Appeals Unit at (802) 828-4368.
Page 1 of 1
revised 9/28/17
B-14 (11/17)

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