File Appeal

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Step 1 of 3: Appeal Request Details

You must answer all items / sections marked with an asterisk (*).

Appeal Filed by *:

Claimant

Attorney/Representative for Claimant

Employer

Attorney/Agent for Employer

Appealable Decisions

Notice of Deputy's Decision:

Decision Mail Date:

Decision of Appeals Examiner:

Decision Mail Date:

Employer Appeal of a Tax Related Decision:

Decision Mail Date:

File Appeal

Claimant Name:

Phone Number *:

Claimant Social Security Number *:

Confirm Social Security Number *:

Employer Name:

Phone Number:

Claimant/Employer Address

Attention:

Country *:

Override Validated Address

Address Line 1 * :

Address Line 2:

City * :

State * :

Zip * :

–

Phone Number *:

Appeal Statements

Reason for Appeal *:

If this appeal is filed after the final date as noted on the Deputy or Appeals Examiner's Decision, you MUST provide an explanation:

Attorney/Representative/Agent Information

Represented by an Attorney/Representative/Agent? *

Name *:

Country *:

Override Validated Address

Address Line 1 * :

Address Line 2:

City * :

State * :

Zip * :

–

Phone Number *:

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