Nhes 0550 - Request For Withdrawal Of Nh Unemployment Claim
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2NHES 0550
New Hampshire Employment Security
Wages & Special Programs Unit
PO Box 2009, Concord, NH 03302-2009
Fax (603) 223-6137
Request for Withdrawal of NH Unemployment Claim
The process to withdraw your NH Unemployment Insurance claim requires that you complete and return
this form by mail, fax or in person to the Wages and Special Programs Unit.
Please refer to instructions for assistance in filling out this form.
Section I
First Name: ________________
Last Name: _____________
SSN: _____________
Mailing Address: ___________________________________
City: ____________________________ State: _______________
Zip: ___________
Reason for Withdrawal (check one):
Severance pay, vacation pay, or any monies that you may have received (other than wages)
from your last employer. (Skip Section II)
Other (Please specify) __________________________________________________(Skip Section II)
Want to file in another State/Combined Wage Claim (Please Complete Section II)
Section II (For Combined Wage Claims)
1) I would like to file my claim in the state of: ________________________________________
If this form is not returned WITHIN SEVEN (7) DAYS of receiving your options, a
New Hampshire Combined Wage Claim will be processed.
2)
I have not received any unemployment insurance benefits as a result of my New Hampshire
combined-wage claim.
OR
I have received unemployment insurance benefits from my New Hampshire combined-wage claim.
a)
I am immediately repaying the State of New Hampshire (attach check or money
order - specify who to make check out to ) in the amount of: $ __________
b)
I agree to have the other State recover the amount of the Overpayment.
Claimant Signature: ____________________________________________ Date: __________
For office use only:
Granted per UCB Policy
NOTES
Not Granted
Staff Initials __________
Program to be withdrawn (check one): [ ] UI [ ] CWC [ ] TRA [ ] DUA [ ] UCFE [ ] UCX
Benefit Year of claim to be withdrawn: ___________________
Effective Date: ______________
TELEPHONE: 603-223-6125
FAX 603-223-6137
TTD ACCESS: RELAY NH 1-800-735-2964
NHDES is an Equal Opportunity Employer and complies with the American With Disabilities Act
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