Form 362 - Request For Hearing & Referral Page 2
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2tHis siDe FoR emploYment DepaRtment use onlY
suppoRting Documents cHecKlist - Request FoR HeaRing & ReFeRRal
Instructions: For each decision for which the appellant requests a hearing, obtain, photocopy and attach to this
hearing request the following supporting documents. Following the list below, check off each document attached.
Forward the hearing request and its supporting documents to the Hearing Officer Panel at the address listed on
the front of this form.
copy
decision type
document
attached?
nonmonetary decision
Administrative Decision appealed
Employer response (letter, completed form, fax) to
Notice of Claim Filed (Form 220), if any. Include copy
of envelope with legible postmark if received by mail.
Any statements, documents/documentation obtained
Note: Do NOT attach/include a copy of
from employer, claimant, other parties, e.g., Form
the INFORMAL decision.
359C Separation Statement, copies of warnings,
letters, etc. Include fact-finding statements taken by
phone. Attach any material referenced in other
documents. include both sides of all two-sided
documents.
Medical or other information that supports either side
of the story
Printout of the week(s) at issue for nonseparation
issues
Tax Section response to Form 1721, if appropriate,
e.g., adjudicator requested Tax investigation of
employer-employee relationship
overpayment decision
Overpayment Decision issued by Overpayment
Recovery Unit
Note: If claimant requests a hearing
Copies of all statements from the employer or
claimant that may shed light upon the circumstances
on the administrative decision
involved in the underlying administrative decision
that created the overpayment,
identify that underlying decision
and include all documentation
associated with it in addition to
the overpayment decision.
Misrepresentation (fraud)
Administrative Decision appealed
Copies of all statements and the documents from
the employer, claimant or witnesses that may explain
the circumstances surrounding the alleged
misrepresentation
Copies of documents containing allegedly false
statements made to the Department to obtain benefits
Form 323 (if available), if wages or wages and hours
claim Determination
of work are missing
(Monetary) decisions
Administrative Decision appealed (usually in the form
of a letter from the Benefit Section to the claimant)
other decisions (tra, dUa, etc.)
Administrative Decision appealed
Copies of signed statements by parties or witnesses
about circumstances surrounding the administrative
decision appealed
Other documents upon which the administrative
decision was based
I certify that I attached copies of all documents indicated above to this Request for Hearing & Referral.
CESN ID:______________________
DATE:__________________
WorkSource Oregon • Employment Department •
Form 362 Back (0308)
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