information on filing a claim to receive reemployment assistance

Transcripción

INFORMATION ON FILING A CLAIM TO RECEIVE
REEMPLOYMENT ASSISTANCE* BENEFITS
• In order to qualify for benefits, you must:
o Have lost your job through no fault of your own
o Be actively looking for a new job
o Be ready to take a new job when offered
o Meet wage requirements based on your previous job(s)
• All claims must be filed online:
o Visit www.FloridaJobs.org/fileaclaim to initiate a claim
o The website is available 24 hours a day, 7 days a week
o Internet and computer services are available free to the public at:
 Public Libraries
 Community Centers
 Senior Centers
• Please have the following information ready to complete your claim:
o Social Security number (SSN)
o Alien registration number and expiration date (if a non-U.S. citizen)
o Name and address of most recent employer(s)
• Complete the Initial Skills Review:
o After filing a claim, all claimants are required to complete the online Initial Skills Review
o THIS IS NOT A TEST
o Results of this review DO NOT impact eligibility
• For more information:
o Visit www.FloridaJobs.org/faq
o Call the Reemployment Assistance Hotline, 1-800-204-2418, Monday – Friday 8 a.m.5 p.m. Eastern and follow the prompts. Requires a touch-tone telephone
*As of July 1, 2012, the Unemployment Compensation program is the Reemployment Assistance program.
An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone
numbers on this website may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.
Form # DEO-UC101 E (Rev. 09/12)
Enfòmasyon pou’w renpli konpansasyon pou’w
ka resevwa Reyanbochaj Asistans* Benefis
• Fason pou’w kalifye pou benefis, ou sipoze:
o Eske’w te pèdi travay epi se pat fòt ou
o Rete aktiv nan chèche yon nouvo travay
o Rete toujou prè pou pren yon nouvo travay yo ofri’w
o satisfè kondisyon salè’w ki baze sou travay anvan ou
• Tout reklamasyon sipoze renpli sou entènet :
o Vizite www.Floridajobs.org/fileaclaim pou ka koumense fè reklamasyon’w lan
o Sit entènet la valab 24 trè pa jou, epi 7 jou pa semèn
o Entènet ak compitè sèvis valab gratis nan tout plas piblik sa yo
 Librèri piblik yo
 Sant kominotè yo
 Sant retrete yo
• Tenpri bat pou genyen enfomasyon sa yo prè pou’w ka konplete reklamasyon’w lan:
o Nimewo Sosyal Sekirit (SSN)
o Nimwo kat rezidans ou ak tout dat ekspirasyon li (si ou pa Sitwayen Amerikin)
o Non ak adrès dènye anplwayè ou te travay pou li an (s)
• Konplete Revizion kalifikasyon konpetans:
o Aprè’w fini renpli reklamasyon’w, tout moun sipoze konplete yon Revizion kalifikasyon
konpetans sou entènèt
o Se pa yon tès li
o Rezilta revu sa a pap fè okenn inpak sou elijibilte’w
• Pou plis ènfòmasyon:
o Vizite http://www.floridajobs.org/faq
o Rele line sistans chomaj la nan, 1-800-204-24-18, Lendi-Vendredi 8 a.m.-5 p.m. lè nan
zòn ès la, epi swiv instriksyo yo. sa a rekòmende pou’w itilize yon telefòn ou ka peze
bouton yo.
*Apati de premye Jiyè, 2012, li pa rele Konpansyon Chomaj pwogram enkò, konnya se Reyanbochaj Asistans pwogram.
Yon anplwayè/pwogram ki bay tout moun menm opòtinite. Gen lòt èd ak sèvis disponib pou moun ki andikape. Moun ki itilize ekipman TT/TDD
kapab jwenn tout nimewo telefòn vwa sou sit entènèt sa a travè Sèvis Relè nan Florid nan 711.
Form # DEO-UC101 C (Rev. 09/12)
INFORMACIÓN SOBRE LA PRESENTACIÓN DE UNA RECLAMACIÓN PARA RECIBIR
ASISTENCIA DE REEMPLEO * BENEFICIOS
•
Con el fin de calificar para beneficios, usted debe:
o Haber perdido su trabajo por razones que no son atribuibles a usted.
o Estar activamente buscando un nuevo trabajo
o Estar listo para aceptar un trabajo nuevo cuando ofrecido
o Cumplir con los requisitos salariales basados en sus trabajos anteriores
•
Todas las reclamaciones deben presentarse en línea:
o Visite www.FloridaJobs.org/fileaclaim para iniciar una reclamación
o La página de Web está disponible 24 horas al día, 7 días a la semana
o Servicios de Internet y de computadora están disponibles gratis al público en:
 Bibliotecas públicas
 Centros comunitarios
 Centros de personas mayores
•
Por favor tenga la siguiente información disponible para completar su reclamación:
o Número de seguro social (SSN)
o Número de registro de extranjero y fecha de vencimiento (si no es ciudadano)
o Nombre y dirección del empleadores más reciente
•
Completar la Revisión Inicial de Habilidades:
o Después de presentar un reclamo, todos los reclamantes están requeridos de completar
la Revisión Inicial de Habilidades en línea
o ESTO NO ES UN EXAM
o Resultados de esta revisión NO impactan la elegibilidad
•
Para más información:
o Visite www.FloridaJobs.org/faq
o Llame la línea de Asistencia de Reempleo al 1-800-204-2418, del lunes al viernes 8
17 oriental y siga las instrucciones. Requiere un teléfono de tonos
* Desde el 01 de julio de 2012, el programa de Compensación de Desempleo es el programa de Asistencia de Reempleo.
Un empleador/programa de igualdad de oportunidades. Ayudas auxiliares y servicios están disponibles a petición a las personas con incapacidades. Todos los
números de teléfono de voz en esta página de Web pueden llegarse por personas con equipo TTY/TDD a través del servicio de retransmisión de Florida al 711.
Form # DEO-UC101 S (Rev. 09/12)
DEPARTMENT OF ECONOMIC OPPORTUNITY
DISASTER UNEMPLOYMENT ASSISTANCE
AFFIDAVIT OF MINOR FAMILY MEMBER EARNINGS
COUNTY OF ___________________
I, ____________________________________________, hereby personally affirm that I am an adult member of the family
group in which ___________________________ worked. I also affirm that he/she is currently unemployed as a direct result of
the disaster that occurred on (Date) __________________.
To support the claim I offer the following statement:
_____________________________________(Name
of
Minor),______________________________(Social
Security
Number)
received $ _____________ as an allowance or a percentage of the proceeds resulting from the business of
_______________________. He/she worked during the proceeding tax year as follows:
_______QTR
_______QTR
_______QTR
_______QTR
_______WKS
_______WKS
_______WKS
_______WKS
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________
I understand that the Florida Reemployment Assistance Law/Disaster Unemployment Assistance and the Stafford Act
provides penalties for knowingly making false statements for the purpose of obtaining RA/DUA benefits. I, therefore, declare
that the statement I have made in connection with this claim is true and correct to the best of my knowledge and belief.
Subscribed and sworn to before me this
the _________ day of _________, 19 _____
__________________________________________
(Affiant's Signature)
Notary Public for Florida
__________________________________________
(Affiant's Social Security Number)
My Commission expires:
______________
__________________________________________
(Address)
OR
__________________________________________
_____________________________________________
(State Department Representative Signature)
_____________________________________________
(Date)
UCB/DUA-12 (3/12)
Item 22
AFFIDAVIT OF MINOR FAMILY MEMBER EARNINGS
COUNTY OF ___________________
I, ____________________________________________, hereby personally affirm that I am an adult member of the family
group in which ___________________________ worked. I also affirm that he/she is currently unemployed as a direct result of
the disaster that occurred on (Date) __________________.
To support the claim I offer the following statement:
_____________________________________(Name
of
Minor),______________________________(Social
Security
Number)
received $ _____________ as an allowance or a percentage of the proceeds resulting from the business of
_______________________. He/she worked during the proceeding tax year as follows:
_______QTR
_______QTR
_______QTR
_______QTR
_______WKS
_______WKS
_______WKS
_______WKS
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________
I understand that the Florida Reemployment Assistance Law/Disaster Unemployment Assistance and the Stafford Act
provides penalties for knowingly making false statements for the purpose of obtaining RA/DUA benefits. I, therefore, declare
that the statement I have made in connection with this claim is true and correct to the best of my knowledge and belief.
Subscribed and sworn to before me this
the _________ day of _________, 19 _____
__________________________________________
(Affiant's Signature)
Notary Public for Florida
__________________________________________
(Affiant's Social Security Number)
My Commission expires:
______________
__________________________________________
(Address)
OR
__________________________________________
_____________________________________________
(State Department Representative Signature)
_____________________________________________
(Date)
UCB/DUA-12 (3/12)
Item 22
STATE OF FLORIDA
AFFIRMATION OF EMPLOYMENT
COUNTY OF __________________
I, _________________________ SS# _____________________, hereby
personally affirm that I was EMPLOYED in the county stated above
on _________________________. To support my claim for EMPLOYMENT
I offer the following statement:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
________________________________________________________
I further state that I understand that the Florida Reemployment
Assistance Law/Disaster Unemployment Assistance and the Stafford
Act provides penalties for knowingly making false statements for
the purpose of obtaining RA/DUA benefits. I, therefore, declare
that the statement I have made in connection with this claim is
true and correct to the best of my knowledge and belief.
___________________________
Claimant's Signature
_________ __________________________
Date
Department Representative
Note: You must provide documentation of employment and earnings
within 21 calendar days of the date you file your claim. Failure
to do so can result in a reduction of your DUA weekly assistance
amount and an overpayment or you may by disqualified from
receiving benefits.
However, documentation submitted with a
request for reconsideration anytime during the twenty six week
disaster assistance period may be accepted.
UCB/DUA-10 (Rev. 3/12)
Item 20
AFFIRMATION OF SELF-EMPLOYMENT
COUNTY OF __________________
I, _________________________ SS# _____________________, hereby personally affirm that I was engaged in SELFEMPLOYMENT activities in the county stated above on _________________________.
To support my claim for SELF-EMPLOYMENT I offer the following statement:
The ending date of the tax year I file for is __________________. The total net earnings for the most recent tax year were
$_____________. My earnings during that tax year were:
_______QTR
______QTR
_____QTR
_____QTR
_______WKS
______WKS
_____WKS
_____WKS
_______EARNINGS
___________EARNINGS
__________EARNINGS __________EARNINGS
There were ______other individuals in my group whose earnings were reported under my Social Security number and who
are also filing for DUA benefits. The net earnings should be allocated as follows:
FULL NAME____________________________ SS#___________________ AGE_____ PERCENT______
RELATIONSHIP______________________
_______QTR
_____QTR
_____QTR
_____QTR
_______WKS
_______EARNINGS
_____WKS
_____WKS
_____WKS
__________EARNINGS __________EARNINGS __________EARNINGS
FULL NAME___________________________ SS#____________________ AGE_____ PERCENT______
RELATIONSHIP______________________
_______QTR
_____QTR
_____QTR
_____QTR
_______WKS
_______EARNINGS
_____WKS
_____WKS
_____WKS
List additional group members to be included on the reverse side of this form.
I further state that I understand that the Florida Reemployment Assistance Law/Disaster Unemployment Assistance and the
Stafford Act provides penalties for knowingly making false statements for the purpose of obtaining RA/DUA benefits. I,
therefore, declare that the statement I have made in connection with this claim is true and correct to the best of my knowledge
and belief.
________________________________ _________ _______________________________
Claimant's Signature
Date
Department Representative
Note: You must provide documentation of employment and earnings within 21 calendar days from the date you file your claim. Failure to do so can result in
a reduction of your DUA weekly benefit amount and an overpayment or disqualification from the receipt of DUA benefits. However, documentation submitted
with a request for reconsideration anytime during the twenty six week disaster assistance period may be accepted.
UCB/DUA-11 (3/12)
1 of 2
Item 21
SELF-EMPLOYMENT AFFIRMATION - CONTINUED
Other individuals in my group whose earnings were reported under my Social Security number and who are also filing for DUA
benefits. The net earnings should be allocated as follows:
FULL NAME_____________________________ SS#_____________________ AGE_____ PERCENT_____
RELATIONSHIP________________________
_______QTR
_____QTR
_____QTR
_____QTR
_______WKS
_____WKS
_____WKS
_____WKS
_______EARNINGS
FULL NAME_____________________________ SS#____________________ AGE_____ PERCENT______
RELATIONSHIP________________________
_______QTR
_____QTR
_____QTR
_____QTR
_______WKS
_____WKS
_____WKS
_____WKS
_______EARNINGS
FULL NAME_____________________________ SS#_____________________ AGE_____ PERCENT______
RELATIONSHIP________________________
_______QTR
_____QTR
_____QTR
_____QTR
_______WKS
_____WKS
_____WKS
_____WKS
_______EARNINGS
RELATIONSHIP________________________
_______QTR
_____QTR
_____QTR
_____QTR
_______WKS
_____WKS
_____WKS
_____WKS
_______EARNINGS
RELATIONSHIP________________________
_______QTR
_____QTR
_____QTR
_____QTR
_______WKS
_____WKS
_____WKS
_____WKS
_______EARNINGS
UCB/DUA-11 (3/12)
2 of 2
Item 21
IMAGING SYSTEM
BATCH INFORMATION COVER SHEET
Scanning Information
(From scanner associates)
Document preparation reviewed by: ________________
Scanned by: __________________________
Date Scanned: ___________________
Quality Assurance by: __________________
Batch #: ________________________
Document Preparation Information
(From unit associate preparing documents for scanning.)
Each batch should have this sheet on top, a Document Category bar code sheet next and then a Single Page
(SP) or Multi-Page (MP) bar code indicator sheet. The MP bar code sheet will be placed on top of each
document to separate the multi-page documents.
Document Category # __________
Unit: __________________________ Worked By / Number Series: ________________
(Claims, Adj, Call Ctr, BPC, Wage Det, etc)
(Optional)
Prepared by: _________________________ Date to Scanner: ____________________
Document Categories
1. Initial Claims (Includes all documents relating
to initial claims.)
7. Payment Issues (Pymt corrections, lost/stolen check
affidavits, child support, etc)
2. Wage Issues (UCB-13s or wage proof, CWC,
federal wage proof, military DD-214s.)
8. EFT
3. Adjudication
9. Appeals/Special Deputy
4. 412s/UCT-1s
10. UAC/Court Orders
5. DUA
11. Benefit Payment Control
6. Continued Claims/Change Requests
(Includes all documents related to continued
claims, including UCB-60, UCB-61s, name or
address changes, ERP notices, work search
records, etc.)
12. Miscellaneous (Subpoenas, requests for document
records, other documents not relating to other
categories.)
13. BTQ
14. BAM
15. BPC Court Documents
377
FLORIDA DEPARTMENT OF ECONOMIC OPPORTUNITY
REEMPLOYMENT ASSISTANCE SERVICES
RSVP EMPLOYMENT INFORMATION FORM
Name _________________________________
Additional Claim ____
If yes:
Comment:
Flag ______
SS# _____________________________
UCB-412 Only ____
SUSP ____
Non/Separation Issue? (Y/N) ____
PEND ____ REJ ____
Start Date __________
________________________________________________________________
STDK ________
Eff. Date ________________
Industry Code _________________
Date Filed ________________
Mail Claim Switch _________________
Employer Name ___________________________________
Account # _______________
Mailing Address ____________________________________________________________
City _______________________________
Date Started Work ___________________
State _______
Last Date Worked ____________________
Total Gross Earnings With This Employer
$_________________________________
Total Gross Earnings Since Sunday Of This Week
Requalify/Earned
3
X
_________________________
Reason For Separation:
Reduced Hours ______
WBA
Zip______________
Since
$__________________________
Claim?
(Y/N)
Permanent/Temporary Layoff (P/T) ______
Quit ______
Discharge ______
Filing
Other ____________________________
Above information obtained during telephone conversation with claimant.
Interviewer's Signature _____________________________
DEO FORM UCB-353 (Rev 2/12)
Date ___________
OFFICE OF APPEALS
NOTICE OF APPEAL
This form may be used to appeal an examiner’s determination for a hearing Appeals cannot be filed at a local “onestop” office. This form is not intended for use in filing an appeal with a District Court of Appeal.
NOTICE TO CLAIMANTS: You must continue claiming, even if you have been denied benefits; otherwise,
additional benefits may not be paid. Direct all questions about your claim to (800) 204-2418.
PLEASE PROVIDE THE FOLLOWING INFORMATION:
Claimant Social Security Number: __________________________________________
Claimant Name: _____________________________________ Telephone: ___________________
Address: ________________________________________________________________________
City: ________________________________________ State: _________ Zip: ________________
Employer Name (if applicable): ______________________________________________________
Account Number (if known): ________________________________________________________________
Address: ________________________________________________________________________
City: ________________________________________ State: _________ Zip: ________________
Contact Person: _______________________________ Telephone: _________________________
REPRESENTATIVE – If you are filing on behalf of a party, provide the following:
Name of Representative: _____________________________________________________
Address: __________________________________________________________________
City: ________________________________ State: _________ Zip: __________________
Contact Person: _______________________ Telephone: ___________________________
REQUEST FOR REFEREE HEARING
I AM APPEALING THE DETERMINATION MAILED_______________. (Attach copy if available.)
Appeals must be filed within 20 calendar days of that date. If not, state the reason for late filing. The date of filing
will be based on the postmark or, if faxed, the date the appeal is date-stamped received by D.E.O.
I appeal because:
( ) I need an interpreter. Specify language: ______________________________.
Signature: _____________________________Print Name:_ _______ ______ _______Date:______________
I am: ( ) the claimant; ( ) the claimant’s representative; ( ) the employer; ( ) the employer’s representative
MAIL OR FAX THIS FORM TO:
D.E.O. Office of Appeals
MSC 347
107 E. Madison Street
Tallahassee, FL 32399-4143
Fax: (850) 921-352
*PRIVACY ACT STATEMENT
Information you provide to this department is voluntary and confidential but is required to process your claim. Pursuant to the
Internal Revenue Code of 1986, the Social Security Act, 42 U.S.C. 1320b-7(a)1, and s. 443.091(1)(h), F.S., disclosure of your
Social Security number is mandatory. Social Security numbers will be used by the department to report the benefits you receive
to the Internal Revenue Service as potential taxable income. In accordance with the Federal Deficit Reduction Act, an
amendment to the Federal Social Security Act, and 5 U.S.C. 552a(o)(1)(D), information you provide is subject to verification
through computer matching programs and information about your wages and claim may be provided to other federal, state and
local agencies or their contractors for verification of eligibility under other government programs to ensure benefits have been
properly paid and for statistical and research purposes.
An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities.
Form: Office of Appeals Notice of Appeal
Rule 73B-20.003 F.A.C.
Form # DEO – A100(E) (05/12)
(DEPATMAN OF OPÒTINITE EKONOMIK)
ASISTANS POU CHOMÈ NAN ZÒN SINISTRE
DWA AK RESPONSABIITE POU AVANTAJ SOSYAL
Ou depoze yon reklamasyon pou Asistans pou Chomè nan Zòn Sinistre (ki rele DUA nan lang angle) dapre Lwa Stafford la. Yo
pral gade si ou kalifye, epi yo pral fè w konnen.
Pou kalifye pou avantaj sosyal pou nenpòt ki semenn nan DUA, ou dwe genyen kondisyon sa a yo :
1.
Ou dwe pa genyen okenn travay, oswa ou kapab genyen yon travay moso jounen sèlman nan yon zòn sinistre leta rekonèt,
poutèt malè ki rive a, epi ou pa dwe gen dwa resevwa avantaj pou asistans pou edew retounen travay nan Eta Florida ni nan
okenn lòt Eta.
2.
Ou dwe remèt papye ki montre kote ou t ap travay ak konbyen ou t ap touche, anvan 21 jou pase apre dat ou depoze
reklamasyon an. DUA kapab koupe nan lajan li peye w chak semenn, epi li kapab deklare li te peye w twòp lajan, oswa ou
kapab pa kalifye ankò pou resevwa avantaj sosyal, si w pa pote papye ou dwe pote yo. Men sèlman, si w remèt papye
ansanm ak yon demann pou yo gade ka w ankò nenpòt kilè pandan peryòd 26 semenn asistans pou chomè nan zòn sinistre
a, yo kapab aksepte papye sa a yo. Pi bon papye pou w remèt, se dènye papye ou te deklare taks pou ane a, oswa W-2 a.
3.
Ou dwe fè reklamasyon pou avantaj sosyal yo san pran reta, dapre direktiv yo bay yo. Si w pa fè reklamasyon pou avantaj
sosyal yo nan lè ou dwe fè l la, sa kapab lakòz reta pou yo peye w, oswa ou kapab pèdi avantaj sosyal ou yo.
4.
Si yo ofri w nenpòt ki travay, ou dwe fè rapò. Si w refize nenpòt travay ou ta dwe aksepte, kote sant pou ede moun jwenn
travay nan zòn ou an (One-Stop Career Center) voye w, ou kapab pa kalifye ankò pou resevwa avantaj sosyal.
5.
Ou dwe kapab, epi ou dwe la, pou pran yon travay tout jounen pandan pifò lè nan semenn nòmal travay ou. Sa vle di ou
dwe pare, ou dwe vle, epi ou dwe kapab aksepte travay ou kapab fè nòmalman, epi pa dwe genyen okenn rezon ni
sikonstans – kit se pèsonèl, fizik (sòf si ou pa kapab travay paske ou te viktim nan malè ki te rive a), ni okenn lòt pwoblèm ki
anpeche w chache oswa aksepte yon travay tout jounen ou kapab kalifye pou li.
Yo pral ba ou yon fòmilè pou chache travay, epi ou dwe ekri ladan tout kote ou kontakte pou travay pandan chak semenn.
6.
Ou dwe rapòte tout travay ou fè, kit yo peye w, kit yo pa peye w pou travay la. Rapòte salè w anvan taks, anvan yo retire
okenn lajan sou ou. Mete tout poubwa ou touche, pou chanm ak pou manje. Ou dwe rapòte lajan ou touche kòm rezèvis
nan lame, oswa nan Gad Nasyonal, tankou salè, menm jan ak lajan pansyon tou.
7.
Si w travay nan pwòp aktivite w, ou dwe rapòte lajan ou resevwa anvan ou peye taks.
8.
Ou dwe rapòte chak fwa ou chanje adrès.
Si w jwenn yon travay, epi ou kwè ou kalifye pou tout avantaj sosyal yo, oswa pou moso ladan yo, ou mèt voye enfòmasyon yo
nan lapòs oswa nan faks ban nou, nan jou ou genyen pou vin rapòte ankò a, oswa anvan. Sonje ekri nan lèt ou a : (1) Non w,
(2) Nimewo sekirite sosyal ou, (3) Dat ou koumanse nan travay la, (4) Konbyen lajan ou touche pou chak jou, depi dat ou
koumanse nan travay la jouk dat ou fè rapò a, (5) Non ak adrès kote ou travay la. Ou kapab voye enfòmason yo nan faks nan
nimewo : (850) 921-3938, oswa bay enfòmasyon yo sou papye nan adrès :
DUA Claims
PO Drawer 5350
Si w gen kesyon sou reklamasyon ou, tanpri telefone 1-800-204-2418. Pa depann sou lòt moun, pou enfòmasyon kòrèk.
Pinisyon pou Koken : Si yon moun fè espre li falsifye, kache, oswa kamoufle nenpòt ki koken, move jwèt, zouti, oswa aksyon ki
fèt, oswa si moun nan fè oubyen sèvi ak nenpòt ki dokiman ekri ki fo, lè li byen konnen dokiman oswa enfòmasyon an genyen
deklarasyon ki fo, ki envante, oswa ki bay manti, moun nan pral kondane pou peye yon amann ki pa depase 10 000 $, oswa pou
li ale nan prizon pou yon (1) ane, pou pi plis, oswa l ap pran 2 pinisyon sa a yo ansanm, pou chak nan fòt sa a yo.
UCB/DUA-2C (Rev 3/12)
Item 9
AYUDA POR DESEMPLEO EN CASO DE DESASTRES (DUA)
DERECHOS Y RESPONSABILIDADES RESPECTO A LOS BENEFICIOS
Usted ha presentado una reclamación de Ayuda por Desempleo en Caso de Desastres (DUA) bajo la Ley Stafford. Se hará una
determinación en cuanto a su elegibilidad y se le notificará sobre la misma.
A fin de ser elegible para recibir beneficios de DUA para cada semana, debe satisfacer las siguientes condiciones:
1.
Debe estar completamente desempleado o parcialmente desempleado debido al desastre, en un área designada zona
de desastre y no tener derecho a recibir beneficios de asistencia reempleo regulares en el Estado de la Florida ni en
ningún otro estado.
2.
Debe proporcionar documentación de empleo e ingresos dentro de un plazo de 21 días civiles desde la fecha en que
presentó su reclamación. La cantidad que reciba de DUA como ayuda semanal podría reducirse y establecerse un
sobrepago, o usted podría quedar descalificado para recibir beneficios, si no suministra la documentación requerida. No
obstante, la documentación presentada con una solicitud para reconsideración en cualquier momento durante el período
de veintiséis semanas de ayuda en caso de desastres podría aceptarse. La documentación preferida es su declaración
de impuestos o su W-2 del año más reciente.
3.
Usted debe reclamar sus beneficios en el momento oportuno como instruido. El fracaso para reclamar que los
beneficios como planificado pueden tener como resultado la demora o la pérdida de sus beneficios.
4.
Usted debe informar cualquier oferta del trabajo hecho a usted. Si usted rehusa referencias adecuadas del trabajo por
su local Centro Único de Servicios, usted puede ser descalificado de recibir beneficios.
5.
Usted debe poder y estar disponible para trabajar a tiempo completo la mayor parte de su semana normal de trabajo.
Esto significa que debe estar listo, dispuesto y capaz para aceptar un trabajo adecuado y que no debe haber ningún
motivo o circunstancia -- personal, física (a menos que no pueda trabajar debido a que quedó incapacitado debido al
desastre), o de otro tipo, que le impida buscar o aceptar un trabajo a tiempo completo para el cual esté calificado.
Se le suministrará un formulario de búsqueda de trabajo en el que deberá listar los contactos con empleadores que
haga cada semana.
6.
Debe informar cualquier trabajo, ya haya recibido o no pago por el mismo. Informe los ingresos brutos antes de
cualquier deducción. Incluya todas las propinas, vivienda y comidas. El pago recibido de la Reserva Militar y la Guardia
Nacional, así como los ingresos de jubilación, deben informarse como ingresos.
7.
Si está empleado por su propia cuenta, debe informar los ingresos brutos cuando los reciba.
8.
Debe informar cualquier cambio en su dirección.
Si encuentra un trabajo y cree que tiene derecho a recibir beneficios totales o parciales, Usted puede enviar o puede
telecopiar la información a nosotros en o antes de su próximo día del informe. Indique: (1) su nombre, (2) su número
de Seguro Social, (3) la fecha en que comenzó a trabajar, (4) sus ingresos cada día desde la fecha en que comenzó a
trabajar hasta el día de su informe y (5) el nombre y la dirección de su empleador. Usted puede telecopiar información a:
(850) 921-3938, o se somete la información por carta a:
DUA Claims
PO Drawer 5350
Si tiene preguntas sobre su reclamación, por favor llamada 1-800-204-2418. No dependa de otras
personas para obtener la información correcta.
Penalidades por fraude: Cualquier persona que a sabiendas e intencionalmente falsifique, oculte o encubra, por medio de
cualquier engaño, plan o ardid, un hecho esencial, o prepare o utilice documentos escritos falsos sabiendo que los mismos
contienen alguna declaración o información falsa, ficticia o fraudulenta, será sancionada con una multa no mayor de $10,000 o
será encarcelada por un máximo de un (1) año, o ambos, por cada violación.
Formulario UCB/DUA-2S (Rev 3/12)
Item 8
BENEFIT RIGHTS AND RESPONSIBILITIES
You have filed a claim for Disaster Unemployment Assistance (DUA) under the Stafford Act. A determination of your
eligibility will be made and you will be notified.
In order to be eligible for benefits for any week of DUA, you must meet the following conditions:
1. You must be totally unemployed, or partially unemployed, in a designated disaster area due to the disaster and
have no entitlement to regular reemployment assistance benefits in the State of Florida or any other state.
2. You must provide documentation of employment and earnings within 21 calendar days from the date you file your
claim. Your DUA weekly assistance amount may be reduced and an overpayment established or you may be
disqualified from receiving benefits for failure to provide the required documentation. However, documentation
submitted with a request for reconsideration anytime during the twenty six-week disaster assistance period may
be accepted. Preferred documentation is your most recent year tax return or W-2.
3. You must claim your benefits on a timely basis as instructed. Failure to claim benefits as scheduled can result in
delay or loss of your benefits.
4. You must report any offer of work made to you. If you refuse any suitable job referrals by your local One-Stop
Career Center, you may be disqualified from receiving benefits.
5. You must be able and available for full time work the major portion of your customary work week. This means
that you must be ready, willing and able to accept suitable work and that there must be no reason or
circumstances - personal, physical (unless unable to work due to incapacitation by the disaster), or otherwise to
keep you from looking for or accepting a full time job for which you are qualified.
You will be furnished a work search form on which you should list any employer contacts you make each week.
6. You must report any work whether or not you have received pay for that work. Report gross earnings before any
deductions. Include all tips, room and meals. Military Reserve and National Guard pay must be reported as
earnings as well as retirement income.
7. If you are self-employed, you must report gross earnings when received.
8. You must report any change in your address.
If you find a job and you think you are entitled to total or partial benefits, you can mail or fax the information to us on or
before your next report day. Remember to include in your letter: (1) Your Name, (2) Your Social Security Number,
(3) The date you began work, (4) Your earnings each day from the date you began work until your report day, (5) The
name and address of your employer. You can fax your information to: (850) 921-3938, or furnish information in
writing to:
DUA Claims
PO Drawer 5350
If you have questions about your claim, please call 1-800-204-2418. Do not depend on others for correct
information.
Penalties for Fraud: Any one who knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or
device, a material fact, or makes or uses any false writing documents knowing the same to contain any false, fictitious
or fraudulent statement or entry will be fined not more than $10,000 or imprisoned for not more than one (1) year or
both for each violation.
Item 7
DUA CLAIM CHECKLIST
Claimant's Name:
Social Security #: ___________________________
To be completed by department representative. Complete this checklist for each DUA claim and attach to front of file
prior to transmittal to the Claims Hub or DUA Unit. All items in Section I are required. In Section II, check only those
items that apply to this claim.
SECTION I
Social Security number is the same on all documents in claim file.
ETA-81, numbers 1 - 32 are completed.
All forms signed by the claimant. (or indicate how the information was obtained i.e., Telephone, Internet).
__
Department representative must sign and date forms when completed, including fact finding forms.
County in which claimant worked or lived is on the list of declared counties for the disaster.
If not, fact-finding statement attached, including county claimant worked in, county claimant lived in, and
specifically how the disaster caused the unemployment.
Claim filed within 30-day filing period.
__ If not, fact-finding statement attached explaining when and how claim was filed and why it was filed late.
SECTION II
Check applicable statements.
Claimant is unemployed as a direct result of the disaster.
If not, fact-finding statement attached.
Claimant was unable to reach the job site due to the disaster.
If yes, fact-finding statement attached.
Claimant was/is unable to work due to an injury caused as a direct result of the disaster.
If yes, fact-finding statement attached, including date of injury and specific cause of injury.
Claimant was unable to begin scheduled employment due to the disaster.
___ UCB/DUA-6 given to claimant or mailed to claimant, to be completed and returned within 21 days.
(Annotate on DUA claim or fact-finding that this was done, and date and sign.)
Claimant was advised of date by which to return any documentation needed to prove employment, selfemployment, and/or wages.
Item 1
DUA WEEKLY CLAIM CERTIFICATION
FOR OFFICE USE ONLY – DO NOT WRITE IN THIS SECTION
SSN
_______-______-________
BP 60 _________________
FEMA ______________________
ISSUE _________________
PROGRAM ID ________________
CLAIMSTAKER
INITIALS
SUPPRESS
SUBSEQUENT__________
__________
IMPORTANT – CAREFULLY COMPLETE THIS FORM AS INSTRUCTED
Claimant’s Name; ________________________________
SS #: _________-_______-_________
MARK THE CORRECT ANSWER
Week Ending
Week Ending
_____-_____-_____
_____-_____-_____
Yes ___ No ___
Yes ___ No ___
(B) Did you contact your last employer to determine if work was
available?
Yes ___ No ___
Yes ___ No ___
1. I claim Disaster Unemployment Assistance for these weeks:
2.
During each of these weeks:
(A) Were you able and available for work?
(C) Did you apply for or receive, or would be eligible to receive if applied for:
(1) Any RA benefits under any other state or federal law?
Yes ___ No ___
Yes ___ No ___
(2) Any amount of loss of wages due to illness or disability? Yes ___ No ___
Yes ___ No ___
(3) Any type of private income protection insurance?
Yes ___ No ___
Yes ___ No ____
(4) Any amount as a supplemental unemployment benefit? Yes ___ No ___
Yes ___ No ____
(5) Any amount of retirement, pension, or annuity income? Yes ___ No ___
Yes ___ No ____
(D) Did you refuse any offer of work?
3.
Yes ___ No ___
Yes ___ No ____
(E) Did you work for another or engage in any self-employment? Yes ___ No ____
Yes ___ No ____
IF YES: Enter gross earnings whether received or not.
(If self-employment, enter gross earnings when received)
$ ___________.____
$ ____________._____
If your mailing address has changed since filing your last certification, mark here and enter new address: ___________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
4.
CERTIFICATION: I certify that I have supplied this information voluntarily in order to obtain Disaster Unemployment
Assistance. I claim assistance for this period with full knowledge that federal funds are provided and that penalties are
prescribed by law for willful misrepresentation or concealment of material facts in order to obtain assistance payments
for which I am not entitled under the Act. I have been furnished a statement required under the Privacy Act of 1974 for
use in the Disaster Unemployment Assistance Program. I certify my statements and answers are true and correct.
Claimant Signature __________________________ Date__________
UCB/DUA – 61 (Rev 03-12)
Phone No (________) __________-__________
Item 10
PO DRAWER 5350
TALLAHASSEE, FLORIDA 32314-5350
SUPPLEMENT FOR SELF-EMPLOYED APPLICANTS
APPLICANT’S NAME (LAST, FIRST, MIDDLE)
DISASTER NO.
FDAA
LO. NO.
DR
SOCIAL SECURITY NO.
–
TYPE OF SELF-EMPLOYMENT (CHECK APPROPRIATE BOX)
ENGAGED IN:
□ FARMING
□ BUSINESS
□ PROFESSION
–
AS A:
□ SOLE OWNER
□ PARTNER
BUSINESS NAME AND ADDRESS (STREET ADDRESS, CITY, STATE, ZIP CODE)
A. FARMING ACTIVITY
IF YOU ARE A SELF-EMPLOYED FARMER, ANSWER THE QUESTIONS IN THIS PART.
1.
WHAT IS THE SIZE OF YOUR FARM?
ACRES
2.
IN THE FOLLOWING COLUMNS, LIST ALL FARM PRODUCTS RAISED AND HELD PRIMARILY FOR SALE AND FARM INCOME.
CROPS
KIND
ACRES
LIVESTOCK
KIND
QUANTITY
OTHER (SPECIFY)
KIND
QUANTITY
B. SELF-EMPLOYMENT INFORMATION
ANSWER ALL QUESTIONS IN THIS PART. USE THE SPACE TO THE RIGHT OF THE QUESTIONS TO EXPLAIN APPROPRIATE ANSWERS.
1.
DESCRIBE THE NATURE OF YOUR SELF-EMPLOYMENT, AND INDICATE HOW LONG YOU HAVE BEEN PERFORMING IT.
2.
DID THIS SELF-EMPLOYMENT REQUIRE ANY PART OF YOUR TIME IN THE PERFORMANCE OF SERVICES? (IF “NO,” EXPLAIN)
YES NO
□ □
3.
4.
5.
6.
7.
WERE YOU PERFORMING ANY SERVICES IN CONNECTION WITH THIS SELF-EMPLOYMENT AT THE TIME OF THE DISASTER? (IF “NO,” EXPLAIN
WHY NOT. IF “YES,” IDENTIFY THE SERVICES BEING PERFORMED)
DID THE DISASTER PREVENT YOU FROM PERFORMING ALL SERVICES IN CONNECTION WITH YOUR SELF-EMPLOYMENT? (IF “NO,” IDENTIFY THE
SERVICES BEING PERFORMED)
SINCE BECOMING UNEMPLOYED, HAVE YOU BEEN PERFORMING OR ABLE TO PERFORM ANY SERVICES IN RESTORING OR IMPROVING THE
VALUE OR PROFIT-MAKING CAPABILITY OF YOUR SELF-EMPLOYMENT?
AT THE TIME OF THE DISASTER, WAS THIS SELF-EMPLOYMENT YOUR PRIMARY OCCUPATION AND PRIMARY MEANS OF LIVELIHOOD? (IF “NO,”
EXPLAIN)
DO YOU HAVE ANY OCCUPATION OTHER THAN THIS SELF-EMPLOYMENT? (IF “YES,” COMPLETE THE INFORMATION REQUESTED)
OCCUPATION:
HOURS PER WEEK:
□ □
□ □
□ □
□ □
□ □
GROSS EARNINGS PER WEEK $
EFFECT DISASTER HAD ON THIS OCCUPATION:
C. SELF-EMPLOYMENT INFORMATION
I CERTIFY THAT THE INFORMATION I HAVE GIVEN ON THIS FORM IS CORRECT, AND THAT I HAVE SUPPLIED THE INFORMATION, VOLUNTARILY IN ORDER TO OBTAIN
DISASTER UNEMPLOYMENT ASSISTANCE. I KNOW THAT FEDERAL FUNDS ARE PROVIDED AND THAT PENALTIES ARE PRESCRIBED BY LAW FOR WILLFUL
MISREPRESENTATION OR CONCEALMENT OF MATERIAL FACTS IN ORDER TO OBTAIN ASSISTANCE PAYMENTS TO WHICH I AM NOT ENTITLED TO RECEIVE UNDER
THE ACT.
I HAVE READ THE STATEMENT REQUIRED UNDER THE PRIVACY ACT OF 1974 FOR USE IN THE DISASTER UNEMPLOYMENT ASSISTANCE PROGRAM.
SIGNATURE OF APPLICANT
DATE (MONTH/DAY/YEAR)
SIGNATURE OF STATE DEPARTMENT REPRESENTATIVE
DATE
FORM ETA 81A (REV 9/11)
Item 3
REEMPLOYMENT ASSISTANCE APPLICATION FOR SERVICES
PLEASE PRINT YOUR INFORMATION IN BLUE OR BLACK INK ONLY FOR ALL ITEMS (on both sides of the application) AND SIGN THIS FORM.
Complete a Supplement for other employment you have had during the last 18 months.
1. Name: (First, Middle, Last)
*Social Security Number: (see Privacy Act Statement on back of form)
—
FOR OFFICE USE ONLY, DO NOT WRITE IN THE GRAY AREA BELOW
1a. Other Names Used During Employment
2. Local Mailing Address:
Street Address:
City:
State:
)
—
or (
5. Sex:
Day
2
M
D
Y
CLAIM
NEW
ADD'L
R/O
UC
X
FE
CWC
EB
UCB-13
MODS
STDK
STATUS
TYPE:
Year
)
ISSUE: (check one)
—
DATE
FILED
T
M
D
Y
REQUALIFY
OTHER
M
F
3
4
5
6
7
/
8
9
10
11
METHOD
NO
YES - enter flag codes
6. Height/Weight
1.
7. (Statistical use only) Are you of Hispanic descent?
YES
NO
Indicate your primary ethnic affiliation:
White (1)
American Indian or
Black or African American (2)
Alaskan Native (4)
Asian (3)
Hawaiian or Pacific Islander (5)
Information not available (6)
8. Identification (ID):
Driver’s License #:
State of Issuance:
_________________________________ _________________________________
State Identification #:________________ State of Issuance:__________________
_____________________________________________________________________
Other ID #:
Type of ID:
____________________________________________________________________
9. Check the number which corresponds to the highest grade you completed:
1. Did not finish High School - Highest grade completed was:
1
EFF
Date
Alternate phone number:
4. Date of Birth:
Month
Apt.#
Residence County:
Zip:
3. Telephone Number:
(
—
12
2. High School Diploma or GED
3. AA or Post Secondary Vocational/Technical Certificate of Completion
4. BS/BA
5. MS/MA
6. Doctorate
LOCAL OFFICE
FIPS
RES. COUNTY
WDB
2.
IND
3.
4.
W/S
ERP
MCS
IB4 STATE/FIPS CODE
Primary DOT Code:
Mo. Exp.
Secondary DOT Code:
Disaster Date:
Documentation presented:
Mo. Exp.
Announcement
Disaster #: FL
TYPE:
________________________________________________________
Secondary DOT
Primary DOT Code:
Mo Exp.
Code:
Mo. Exp.
________________________________________________________
10. Are you handicapped as defined in Section 504 of the
Rehabilitation Act of 1973?
YES
NO
Definition: A person is handicapped if he or she has a physical or
mental impairment which substantially limits one or more major life
activities; has a record of such impairment; or is regarded as having
such impairment.
NOTE: This information will be used for statistical purposes only; is
requested on a voluntary basis; and will be kept confidential.
YES
NO
Alien Reg. #:
YES
NO
Expiration Date:
Lawfully Admitted Alien/Refugee
11b. If not fluent in English, what language do you prefer to use?
Haitian Entrant
Other
11. I am a citizen of the United States.
If no, I am authorized to work in this country.
11a. Citizenship:
US Citizen/Nationalized
Cuban Entrant
12. I hereby apply for DUA for the period beginning:
Employer ID # ___________________________________________
_____________________________________________________________________
13. TYPE INDUSTRY OF EMPLOYER:
14. Unemployment was a result of this disaster because:
___________________________________________________________________
15. Name of employer at time of disaster:
Employer's Street Address
Dates Worked:
FROM:
City
Supervisor’s Name:
County
Employer's Telephone Number:
(
)
Form ETA-81 (Rev. 03/12)
—
State
Zip
County in which worked:
Mo.
Occupation:
TO:
Day
Total Gross Earnings
Salary Rate:
Total Gross Earnings since
$
Per *
Sunday of this week:
(*Hour, Week, Month, Year) Occupation or Title:
Year
Mo.
$
Day
Year
Reason for Separation:
Permanent Lay-off
Temporary Lay-off
Quit or Voluntary Lay-off
Working Reduced Hours
Explain Reason for Separation:
Suspension
Leave of Absence
Discharged, Job Performance
Discharged, Other
Tools/Equipment Used:
Are you scheduled to return to work for this employer?
YES
When?
NO
16. Are you currently employed, self-employed or have you been self-employed in the past year?
YES
NO
17. Is there any reason you cannot seek or accept full-time employment?
YES
YES
NO
NO
17A. Have you refused any offer of work since you became unemployed?
18. Did you apply for or receive, or would you be eligible to receive if applied for: (Mark "Y" for Yes or "N" for No next to each question)
Any amount for loss of wages due to illness or disability?
Any amount of retirement pension or annuity income?
Any type of private income protection insurance?
Worker's compensation for death of head of household?
Any amount as supplemental unemployment benefit?
___________________________________________________________
19. Have you received, or will you receive any of the following payments?
Severance Pay
YES
NO
Wages in Lieu of Notice
YES
NO
Vacation Pay
YES
NO
Amount: $
From:
To:
20. Do you have specific plans to enroll in or attend school or vocational training within the next 12
months?
If yes, when?
YES
NO
YES
NO
a. Been in the Military Service?
YES
NO
b. Held a Federal Civilian Job?
YES
NO
c. Worked in any other state?
YES
NO
YES
NO
(date)
21. Are you receiving, or will you receive a retirement pension?
If yes, date payment began/will begin:
Employer's Name:
22. During the past 18 months, have you:
23. Have you applied for Reemployment Assistance benefits in the past 12 months?
If yes, against which state?
24. If you receive, or will receive payments from Worker's Compensation, is it classified as:
Temporary Total
Permanent Total
YES
YES
NO
NO
Temporary Partial
Supplemental Income
YES
YES
25. Are you a member of a labor union which finds/obtains work for its members?
NO
NO
Impairment Income
YES
YES
NO
NO
If yes, provide Union name and number:
26. What type of work are you seeking?
27. Are you a veteran who meets one or more of the following conditions?
a. Served on active duty for a period of more than 180 days and received a discharge other than dishonorable.
b. Was a reservist who earned a campaign badge and was released or discharged with a discharge other than dishonorable?
c. Was discharged or released from active duty because of a service-connected disability?
YES
NO
YES
NO
If you answered yes to Question 25 above, please answer questions 26 – 30 below, otherwise go to question 31.
28. Were you released from military active duty within the last three years (36 months)?
29. Did you serve on active duty during a war, campaign or expedition for which a campaign badge has been authorized?
YES
NO
30. Are you a Disabled Veteran?
YES
NO
Definition: You have a service-connected disability which entitles you to compensation or caused you to be discharged or released from active duty.
YES
NO
31. Are you a Special Disabled Veteran?
Definition: You are entitled to compensation for a service-connected disability rated at 30 percent or more or 10 or 20 percent with a determination
that you have a serious employment handicap or you were discharged or released from active duty because of service-connected disability.
32. Are you a homeless veteran?
YES
NO
33. Are you the spouse of any of the following individuals?
YES
NO
(a) a veteran who died of a service connected disability; (b) a veteran who has a total service-connected disability; (c) a member of the Armed Forces
serving on active duty who has been listed for a total of more than 90 days in one of the following categories: (I) missing in action; (II) captured in line
of duty by a hostile force; or (III) forcibly detained in the line of duty by a foreign government?
34. If you answered ‘Yes’ to Question 25 or 31 above, you qualify for Special Job Service Veteran’s Assistance through the local One Stop Center
in your area and, unless told otherwise at the time you complete this application, you should report to that office to register for Veteran’s assistance.
I hereby claim benefits under the Florida Reemployment Assistance Law. I am not seeking benefits under any other state or Federal system. At the
discretion of the department, this application for benefits may be accepted as my registration for work and employment services. I understand the Florida
Reemployment Assistance Law provides penalties for knowingly making false statements for the purpose of obtaining benefits. I declare that the statements
made in connection with this claim are true and correct to the best of my knowledge and belief. I understand the information is subject to verification and
agree to provide such documentation as required.
Claimant Signature:
Date:
The Department of Economic Opportunity may e-mail me for additional information needed in determining my claim.
My E-Mail Address is:__________________________________________________
I understand the Department of Economic Opportunity will maintain the confidentiality of my e-mail address pursuant to section 443.1715, Florida Statutes.
Information you provide to this department is voluntary and confidential but is required to process your claim. Pursuant to the Internal Revenue Code of
1986, the Social Security Act, 42 U.S.C. 1320b-7(a)1, and s. 443.091(1)(h), F.S., disclosure of your Social Security number is mandatory. Social Security
numbers will be used by the department to report the benefits you receive to the Internal Revenue Service as potential taxable income. In accordance with
the Federal Deficit Reduction Act, an amendment to the Federal Social Security Act, and 5 U.S.C. 552a(o)(1)(D), information you provide is subject to
verification through computer matching programs and information about your wages and claim may be provided to other federal, state and local agencies or
their contractors for verification of eligibility under other government programs to ensure benefits have been properly paid and for statistical and research
purposes.
(DEPATMAN OF OPÒTINITE EKONOMIK)
ASISTANS POU CHOMÈ NAN ZÒN SINISTRE
DIREKTIV POU VOYE REKLAMASYON DUA NAN LAPÒS
Y ap mete non w nan yon sistèm ki pèmèt ou voye fè rapò reklamasyon w nan lapòs. Sa vle di ou pral voye kat
sètifikasyon pou reklamasyon w Tallahassee, nan lapòs. Nan chak kat sètifikasyon, genyen 1 oswa 2 semenn ki ekri. Dat
nan semenn yo parèt nan kote ki make nimewo 1 sou kat la. Pou fè reklamasyon pou avantaj sosyal pou semenn ki ekri a
(yo), ou dwe reponn tout kesyon pou semenn ki ekri a (yo). Pou make repons ou, nwasi ti wonn ki kote kesyon yo, anba
dat ki ekri pou chak semenn nan. Sèvi ak yon plim ki ble oswa nwa, oubyen yon kreyon nwa fonse pou reponn kesyon yo.
Si w pa reponn tout kesyon yo, pou chak semenn w ap fè reklamasyon, sa pral lakòz chèk ou gen reta. Ou dwe siyen epi
mete dat sètifikasyon an anba kat la. Si w genyen tout kondisyon pou kalifye yo, n ap voye yon chèk ba ou lè nou resevwa
kat sètifikasyon ou avèk tout enfòmasyon yo ekri ladan. Si w bezwen ekri lòt enfòmasyon toujou, pou nenpòt nan repons
ou bay pou kesyon yo, ou dwe bay enfòmasyon sa a yo sou yon fèy papye separe, epi mete papye a nan yon anvlòp pou w
voye nan lapòs ansanm ak kat sètifikasyon an. Voye kat sètifikasyon an, avèk enfòmasyon yo ekri ladan l, bay :
DUA CLAIMS
P.O. DRAWER 5350
POU VOYE REKLAMASYON W NAN LAPÒS
• Ou pral resevwa kat sètifikasyon pou fè reklamasyon chak 2 semenn nan lapòs. Sou chak kat, dat pou voye l
la ap ekri nan kwen anwo adwat la.
• Ou dwe voye yon kat nan lapòs chak 2 semenn, nan dat ki ekri nan kwen anwo adwat la. Se responsabilite w
pou voye kat la nan lapòs alè. Si w voye yon kat nan lapòs anvan dat yo ekri pou voye l la, y ap retounen l ba
ou.
• Si w voye yon kat nan lapòs apre dat yo ekri pou voye l la, sa pral lakòz chèk ou gen reta. SI RAPÒ W LA
GEN PLIS PASE 14 JOU RETA, YO PA KAPAB VOYE OKENN PEMAN BA OU. Kenbe yo dosye ki montre
nan ki dat ou voye kat sètifikasyon an nan lapòs.
• SI 10 JOU GEN TAN PASE DEPI OU TE VOYE RAPÒ W NAN LAPÒS OSWA POTE L REMÈT NAN MEN,
EPI OU PAKO RESEVWA KAT SÈTIKASYON POU VOYE APRE A,
TELEFONE 1-800-204-2418.
POU FÈ RAPÒ NAN SANT POU EDE MOUN JWENN TRAVAY LA (ONE STOP CAREER CENTER)
Tanzantan, yo kapab mande w vini oumenm, nan sant pou ede moun jwenn travay la (One Stop Career Center)
pou gade si w toujou kalifye, oswa paske yo vle mande w yon kesyon sou reklamasyon w nan. Y ap ekri w nan
lapòs pou fè w konnen ki dat, ki lè, ak ki kote pou w vini, oumenm, pou rapò a. Chak fwa w ap vini nan sant la,
pote nenpòt ki kat sètifikasyon pou semenn ou genyen, ansanm ak dosye ki montre kote ou chache travay yo, pou
fè wè ki efò ou fè pou jwenn travay depi dènye fwa ou te vini, oumenm, nan biwo a pou rapò a.
SI W KOUMANSE NAN YON TRAVAY
Si w ap travay lè jou a rive pou fè rapò sou reklamasyon w nan, ou dwe ekri enfòmasyon yo mande nan kat
sètifikasyon w nan, epi voye l nan lapòs. Sèvi ak yon fèy papye separe pou di non ak adrès kote w ap travay la,
dat ou te koumanse travay, ak konbyen ou touche chak semenn (si w ap touche), pou semenn ki ekri sou kat la.
OU DWE TELEFONE 1-800-204-2418 SI :
1.
y ap peye w pou nenpòt nan semenn ki ekri sou kat la, epi ou p ap travay ankò, epi ou vle kontinye fè reklamasyon
pou avantaj sosyal.
2.
ou koumanse ale lekòl, oswa ou sispann ale nan yon pwogram fòmasyon ki kalifye.
3.
ou genyen plis pase 14 jou reta, pou yon rapò ou dwe fè.
UCB/DUA-68C (Rev 9/11)
Item 16
AYUDA POR DESEMPLEO EN CASO DE DESASTRES (D.U.A.)
INSTRUCCIONES PARA PRESENTAR RECLAMACIONES DE D.U.A. POR CORREO
Su nombre se está ingresando en un sistema de informes de reclamación por correo. Esto significa que
usted enviará sus tarjetas de certificación de reclamación por correo a Tallahassee. En cada tarjeta de
certificación se lista una o dos semanas. Las fechas de la(s) semana(s) se muestran en el punto número
1 de la tarjeta. Para reclamar beneficios por la(s) semana(s) indicada(s), debe contestar todas las
preguntas que aparecen bajo cada semana indicada. Marque sus respuestas llenando el círculo correcto
para cada pregunta bajo las fechas de cada semana. Utilice una pluma con tinta azul o negra, o un lápiz
de grafito oscuro para contestar las preguntas. Si no contesta todas las preguntas para cada semana que
está reclamando, su cheque se demorará. Debe firmar y fechar la certificación al pie de la tarjeta. Si
satisface todos los requisitos de elegibilidad, se le enviará un cheque por correo cuando recibamos su
tarjeta de certificación debidamente llena. Si necesita añadir información adicional para cualquiera de sus
respuestas a las preguntas, deberá suministrar dicha información en una hoja de papel por separado y
enviarla por correo en un sobre con la tarjeta de certificación. Envíe por correo la tarjeta de certificación
llena a:
D.U.A. CLAIMS
P.O. DRAWER 5350
TALLAHASSEE, FL 32314-5350
COMO ENVIAR SU RECLAMACION POR CORREO
• Usted recibirá las tarjetas de certificación de reclamación por correo cada dos semanas.
Cada tarjeta tendrá una fecha de envío en la esquina superior derecha.
• Debe enviar una tarjeta cada dos semanas, el domingo siguiente a la segunda semana que
se lista en la tarjeta. Usted es responsable de enviar la tarjeta a tiempo. Las tarjetas que se
envíen antes de la fecha de envío indicada se le devolverán a usted para que las vuelva a
enviar.
• Su cheque se demorará si envía la tarjeta después de la fecha de envío programada. NO SE
EFECTUARA NINGUN PAGO SI ENVIA SU INFORME MAS DE 14 DIAS TARDE. Mantenga
un registro de las fechas en que envíe sus tarjetas de certificación.
• SI USTED NO RECIBE SU PROXIMA TARJETA DE CERTIFICACION DENTRO DE UN
PLAZO DE 10 DIAS DESPUES DE SU ULTIMO, USTED DEBE LLAMAR 1-800-204-2418.
REPORTES EN EL CENTRO DE EMPLEO
Es posible que periódicamente se le notifique que debe reportarse en persona a su local Centro
de Empleo para una revisión de elegibilidad o debido a que haya alguna pregunta con respecto a
su reclamación. Su próxima fecha de reportarse en persona se indicará en su folleto de
identificación, o se le notificará por correo la fecha, la hora y el lugar en que debe reportarse.
Cuando se reporte a el Centro de Empleo, lleve consigo cualquier tarjeta de certificación de
reclamación semanal que tenga y su registro de búsqueda de trabajo mostrando sus esfuerzos
para buscar trabajo desde la última vez que se reportó a la oficina en persona.
SI COMIENZA A TRABAJAR
y está trabajando cuando sea tiempo de reportarse por correo o en persona, debe llenar su
tarjeta de certificación de reclamación y enviarla por correo. Incluya en una hoja de papel por
separado el nombre y la dirección de su empleador, la fecha en que comenzó a trabajar y sus
ingresos semanales (de haberlos) por las dos semanas listadas en la tarjeta.
USTED DEBE LLAMAR 1-800-204-2418 SI:
1.
2.
3.
obtiene ingresos durante cualquiera de las semanas que se indican en la tarjeta, ya no está
trabajando, y desea continuar reclamando beneficios.
comienza a asistir a la escuela o descontinúa el adiestramiento aprobado.
está más de 14 días tarde en presentar el informe.
UCB/DUA-68S (Rev 09/11)
Item 15
INSTRUCTIONS FOR FILING DUA CLAIMS BY MAIL
You are being placed on a mail claim reporting system. This means you will be mailing your claim certification
cards to Tallahassee. There are one or two weeks listed on each certification card. The dates of the week(s) are
shown in item number 1 on the card. To claim benefits for the week(s) shown, you need to answer all of the
questions under each week shown. Mark your answers by filling in the correct circle for each question under the
dates shown for each week. Use a blue or black pen or a dark lead pencil to answer the questions. If you do not
answer all of the questions for each week you are claiming, your check will be delayed. You must sign and date
the certification on the bottom of the card. If you meet all of the eligibility requirements, a check will be mailed to
you when we receive your properly completed certification card. If you need to add additional information to any of
your answers to the questions, you should furnish that information on a separate sheet of paper and mail it in an
envelope with the certification card. Mail the completed certification card to:
DUA CLAIMS
P.O. DRAWER 5350
MAILING YOUR CLAIM.
• You will be receiving claim certification cards in the mail every other week. Each card will have a
mailing date in the upper right hand corner.
• You are scheduled to mail a card every two weeks, on the mailing date in the upper right hand corner.
It is your responsibility to mail the card on time. Cards mailed before the mailing date shown will be
returned to you.
• Your check will be delayed if you mail the card after the scheduled mailing date. NO PAYMENT CAN
BE MADE IF YOUR REPORT IS MORE THAN 14 DAYS LATE. Keep a record of when you mail
your certification cards.
• IF YOU DO NOT RECEIVE THE NEXT CERTIFICATION CARD WITHIN 10 DAYS AFTER YOUR
LAST MAILED OR IN-PERSON REPORT, CALL 1-800-204-2418.
REPORTING TO THE ONE STOP CAREER CENTER.
Periodically you may be notified to report to the local One Stop Career Center for an eligibility review or
because there is a question concerning your claim. You will be notified by mail of the date, time and place
to report for your next in-person report. Whenever you report to the Center, take any weekly claim
certification card that you may have and your work search record showing your efforts to seek work since
your last in-person report to the office.
IF YOU START A JOB
If you are working when it is time to report on your claim, you should complete your claim certification card
and mail it. Include on a separate sheet of paper the name and address of your employer, the date you
started to work and your weekly earnings (if any) for the weeks listed on the card.
YOU MUST CALL 1-800-204-2418 IF:
1.
you have earnings during any of the weeks shown on the card, are no longer working and wish to continue
claiming benefits.
2.
you start to school or discontinue approved training.
3.
you are more than 14 days late in making a report.
UCB/DUA-68 (Rev 09/11)
Item 14
INFORMASION
ASISTANS POU EDEW RETOUNEN TRAVAY
(RA)
Ou pe tet kapab kalifìe pou touche RA (Reemployment Assistance) règilìe a si:
Ou pap travay totalman ou dèmi èpi, ou pa koupab èpi;
Out tè travail pendan de (2) trimes nan gnou period ke leta bien determine,
(period sa‘a you rele li an engle: base period) e poi out e gagne gnou saler ke ecal
a gnou minimum de 1.5 foi ke trimes ke pi cro nan base period la e ki pa pi piti ke
$3400.
Ou Kapab è disponib pou travay.
Pou rempli aplikasion pou “RA” benèfis ou douè founi:
Nimèro Social Sèkititè-ou;
Ou lot idantitè;
Si ou pa citoyen Amèrikin, dokiman Imigrasion kè yap chèkè avek sèvis “INS”
pou pèmi travay;
Non ak adres travay pou 18 mwa ke sot pasè (lan Floride è tout kotè ou travay lan
ètazini).
Pou rèsèvoi “RA” ou douè pare akseptè tout kalitè travey yo ofri ou.
UCB/DUA-7(C) (REV. 3/12)
Item 26
INFORMASION
ASISTANS CHOMAY AKOZ DÈGA
(DUA)
Ou kapab kalifiè pou “DUA” si:
Ou pap travay totalman, ou bien adèmi akoz frèdi lan Desam, èpi;
Ou pa kalifìè pou benefis règiliè lèta Floride, ou bien okin lot èta lan ètazini ou
bien ou fini èpizè bènèfis ou è guinyin; èpi
Ou Kapab è disponib pou travay.
Pou rempli aplikasion pou “DUA” bènèfis ou douè founi:
Nimèro Social Sèkititè-ou;
Ou lot idantitè;
Si ou pa citoyen Amèrikin, dokiman Imigrasion kè yap chèkè avek sèvis “INS”
pou pèmi travay;
Non ak adres travay pou 18 mwa ki sot pasè
Tout ti mozo rèsi kotè out è travay pou dèniè 18 MWA ki sot pasè;
Si ou tap travay pout et pa rou, ou douègouni rèsi Federal Income Tax” ou bien
dèclarasion benefis ou bien sa ou pèdi.
Pou rèsevoi “DUA” ou douè inskri ak “Job Service” èta Florida èpi tou pare pou akseptè
tout travay yo ofri ou.
UCB/DUA-7(C) (REV. 3/12)
Item 26
INFORMACIÒN
BENEFICIOS DE ASISTENCIA REEMPLEO
(RA)
Usted puede ser elegible para beneficios por reempleo estales (RA) si:
Está totalmente o parcialmente desempleado por causas agenas a su voluntad; y
Se le ha pagado sueldo en más de dos trimesters durante el periodo base y el
sueldo total es equivalente a 1 ½ veces la cantidad ganada durante el trimester
mas alto, pero no menos de $3400; y
Está capacitado y disponible a trabajar y activamente buscando trabajo.
Para reclamar RA, a usted se le pedirá que proporcione lo siguiente:
Su número de seguro social;
Una otra identificación;
Si usted no es ciudadano de los Estados Unidos, su documento de inmigrante de
el Servicio de Immigraciòn y Naturalizaciòn (INS). Su autorizaciòn de trabajo
sera verificada con el INS;
Los nombres y direcciones de todos los patrones con los cuales usted a trabajado
(en la Florida y cualquier otro estado) durante los ùltimos 18 meses;
Cualquier comprobante de pago que usted haya recibido durante los ùltimos 18
meses;
Para recibir RA usted debe estar dispuesto ha aceptar cualquier trabajo apropiado que se
le ofresca.
UCB/DUA-7(S) (REV. 3/12)
Item 25
INFORMACIÒN
ASISTENCIA PARA DESEMPLEO POR DESASTRE
(DUA)
Usted puede ser elegible para DUA si:
Está desempleado o parcialmente desempleado debido a un desastre declarado; y
No es elegible para beneficios de otras estatales o federales en la Florida u
otro estado o si ha agotado todo los beneficios de reempleo disponible a usted; y
Està capacitado y disponible para trabajar.
Para aplicar para DUA, a usted se le pedira que proporcione lo siguiente:
Su nùmero de seguro social;
Una otra identificaciòn;
Se usted no es ciudadano de los Estados Unidos, su documento de inmigrante de
el Servicio de Immigraciòn y Naturalizaciòn (INS). Su autorizaciòn de trabajo
serà verificada con el INS;
Los nombres y direcciones de todos los patrones con los cuales usted a trabajado
(en la Florida y cualquier otro estado) durante los ultimos 18 meses;
Cualquier comprobante de pago que usted haya recibido durante los ùltimos 18
meses;
Se trabaja por su cuenta, su ùltima declaraciòn de ingreso de impuestos federal o
su declaraciòn de ganacias y perdidas.
Para recibir DUA usted debe estar dispuesto ha aceptar cualquier trabajo apropiado que
se le ofresca.
UCB/DUA-7(S) (REV. 3/12)
Item 25
INFORMATION
(DUA)
You may be eligible for DUA if:
You are unemployed or partially unemployed due to the recently declared disaster; and
You are not eligible for regular or extended benefits in Florida or any other state or you
have exhausted all reemployment assistance benefits available to you; and
You are able and available for work.
To file a DUA claim, you will be asked to furnish the following:
Your Social Security number;
One other form of identification;
If you are not a U.S. Citizen, your Immigration and Naturalization (INS) documentation.
This information will be verified with INS for current work authorization;
The names and addresses of all employers you have worked for (in Florida and any other
state) during the past 18 months;
Any check stubs you may have for employment within the last 18 months;
If self-employed, your latest Federal Income Tax returns and/or profit and loss statements.
To receive DUA you must be willing to accept any suitable work offered to you.
UCB/DUA-7 (REV. 3/12)
Item 24
INFORMATION
REEMPLOYMENT ASSISTANCE BENEFITS
(RA)
You may be eligible for regular state RA if:
You are unemployed or partially unemployed through no fault of your own; and
You have worked in two calendar quarters of your base period and have earned wages equal
to at least 1.5 times your highest quarter in your base period and not less than $3400.
You are able and available for work and actively seeking work.
To file a RA claim, you will be asked to furnish the following:
Your Social Security number;
One other form of identification;
If you are not a U.S. Citizen, your Immigration and Naturalization Service (INS)
documentation. This information will be verified with INS for current work authorization;
The names and addresses of all employers you have worked for (in Florida and any other
state) during the past 18 months;
Any check stubs you may have for employment within the last 18 months.
To receive RA you must be willing to accept any suitable work offered to you.
UCB/DUA-7 (REV. 3/12)
Item 24
1.
POUKISA ÈSKE PWOSÈ SA A ENPÒTAN?
Desizyon ki soti nan odyans sa a pral ranplase desizyon
sa yo ki te fè apèl. sèlman yon sèl nivo tande lalwa mande
sa. Pou pwoteje dwa w, ou dwe patisipe menm si lòt pati
a depoze apèl la. si ou pa kapab ale nan kòm pwograme,
imedyatman swiv enstriksyon ki nan seksyon 9 mande
pran yon lòt randevou. sinon ou resevwa yon pouvwa
defavorab decision.a claimaint ki resevwa yon desizyon
favorab ap gen repeye benefis ki pa ta dwe gen peye .
anplwayè ki resevwa yon desizyon favorab pouvwa
resevwa benefis akizasyon ki ogmante to taks anplwayè-a
oswa mande pou ranbousman fè konfyans la fon. Prepare
w pou prezante prèv sou tout pwoblèm ki make sou avi a
pou tande. desizyon an ap baze sou prèv ki prezante nan
odyans lan. fè apèl kont yon nivo dezyèm egziste, men
sèlman yon revizyon kap fet sou dosye ki egziste a, pa
yon odyans nouvo.
2. POUKISA YON ODYANS PWOGRAME?
Yon odyans pwograme paske te gen yon desizyon Ajans
lan pran epi apèl fèt . patisipe nan odyans lan enpòtan.,
menm si se lòt pati a ki depoze apèl la.
3. KISA K AP RIVE SI MWEN PA PATISIPE?
si pati a ki te ranpli apèl la ap patisipe yon odyans ap fèt.
desizyon an pral sou prèv ki prezante. si ou pa patisipe.
prèv ou p ap konsidere. si ou te ranpli apèl la epi ou pa
patisipe, ka ou a ap rejte.
4.
KI DWA MWEN GENYEN PANDAN PWOSÈA?
Antanke yon pati, ou genyen dwa:
A. Pou temwaye pou pwòp tèt pa w;
B. Pou prezante dokiman yo ak lòt prèv;
C. Pou fè temwen esansyèl temwaye;
D. Pou poze pati ki kont ak temwen yo keksyon;
E. Pou eksplike oswa kontredi prèv;
F. Pou fè yon deklarasyon a la fen de pwosè-a;
G. Pou egzamine epi pou rejte nenpòt dokiman ki vin
aksepte kòm prèv.
5.
KOUMAN ÈSKE MWEN KA PLANIFYE POU
ASISTANS TEMWEN YO?
Kontakte epi mande poze temwen an temwaye. temwen
ki pi bon an se youn ki gen konesans pèsonèl nan
enfòmasyon yo. yon temwen ki moun ki te prezan nan
evennman an se pi bon pase yon moun ki te di sou li lè
yon lòt moun. si sa posib, ou menm ak temwen ou ta dwe
nan pozisyon an menm pou odyans lan. si yon temwen pa
kapab nan pozisyon ou epi ou dwe kontakte nan yon
nimewo telefòn diferan. tanpri bay non an ak nimewo
telefòn temwen clerck la depite ki gen non ak nimewo
telefòn parèt sou avi a nan seyans lan telefòn. moutre
temwen an li dwe disponib nan moman odyans lane pi
rete disponib jiskaske ou ranvwaye oswa abit la.
10. KOUMAN MWEN KA JWENN YON KOPI
NAN DOSYE A?
kopi tout dokiman yo disponib pou abit la . yo fèmen ak
avi pou adyans lan. revize epi gen dokiman yo ansanm
ak ou pandan odyans lan.
Si yon temwen refize temwaye volontèman, ou ka
mande yon manda lè w ekri nan adrès ki sou avi a.
Lapòs oswa nan faks demann lan pi vit ke posib, se
konsa manda a ap sèvi anvan odisyon lan. mete nimewo
dosye nan ka, non temwen an , adrès ak nimewo telefòn
(si disponib) osi byen ke detaye deskripsyon nenpòt ki
dokiman temwen an founi pou odyans lan.
11. KIJAN ÈSKE MWEN KA JWENN YON KOPI
DOKIMAN DOSYE YO?
prèv ki pi bon se temwayaj ki soti nan yon moun ki te
prezan nan evennman an ak ka reponn kesyon espesifik
sou sa ki rive. moun kap fè reklamasyon prèske toujou
gen premye konesans nan evènman yo. Anplwayè ta dwe
chwazi temwen ak anpil atansyon asire konpetan prèv yo
prezante.
6. KOUMAN ÈSKE MWEN KA PWOUVE MWEN
TE DISPONIB POU TRAVAY?
Si pwoblèm nan se si ou te kapab ak disponib pou travay.
voye yon kopi fèy papye rechèch travay ou kontak nan
Biwo Apèl la anvan odisyon an. gen ladan chak dat
kontakte travay ak metòd, menm jan tou non chak
konpayi travay yo kontakte ak adrès ou.
7.
KOUMAN ÈSKE MWEN KA PWOUVE MWEN
TE FÈ DEMANN DAPÈL MWEN AN ATAN?
Si apèl la pa prezante lan tan ke lalwa otorize a . Abit la
pral pran premye prèv la opòtinite pou apèl la. si se
ponktyalite ki nan lis kòm yon pwoblèm, moun ki depoze
apèl la pral yon temwen enpòtan. l pwosè a ap anile san
pa prèv konpetan nan ranpli alè.
8.
E SI MWEN CHANJE LIDE E MWEN DESIDE
PA FÈ DEMANN DAPÈL LA ANKÒ?
Demandè-a kapab retire demann dapèl-la si li ekri yon lèt
oswa si li voye yon faks nan Biwo Apèl-la; adrès ak
nimewo faks-la ekri sou Avi Pwosè-a oswa nan adrès saa: Office of Appeals; MSC 347; 107 E Madison Street;
Tallahassee, Florida 32399-4143.
Nimewo Sekirite
Sosyal reklamè-a ak nimewo dosye apèl-la dwe parèt sou
tout korespondans. Nan pifò nan majorite sitiyasyon-yo,
si w deside pou fèmen yon demann dapèl, ou paka fè
ouvri l ankò.
9. ESKE MWEN KA MANDE POU YO
RANVWAYEL?
Ou kapab mande pou ranvwayel si gen yon rezon poukisa
ou pa ka patisipe nan orè.. ou kapab fè sa pa ekri anvan
odyans la oswa sou dosye a pandan odyans lan .mete a
rezon ki fè oupa ka patisipe, epi ki sa, si genyen, eseye
ou te fè re ranje orè ou pou ou te ka patisipe. abit la ap
kite w konnen alekri si yo akòde demann lan. si yon reply
ekri pa resevwa. asime te fè demann la refize. Fèt pou
disponib pou odyans la epi prepare prezante ka ou.
Si yon dokiman ou deja soumèt pa enkli ak avi odyans
lan, ou dwe voye yon lòt kopi bay ofisye odyans lan ak
tout lòt adrès ki sou avi seyans telefòn lan . Pou nou
kapab konsidere dokiman yo .
pou konsidere dokiman, poste faks oswa delivre yon
kopi chak biwo apèl yo ak tout adrès ki sou avi odyans
lan anvan dat odyans la. dokiman sèlman resevwa pa tout
pati yo ap konsidere, sòf si se dwa pou yo sèvi ak
dokiman yo egzante yo. tout prèv vin dosye piblik lè se
odyans la reyini
Pifò dokiman yo ak deklarasyon sou sèman yo se humeur
ou gen dwa pou itilize pou objektif la pou suplementing
oubyen eksplike lòt prèv oswa nan apiye yon konklizyon
si li ta admisib sou plis pase yon objeksyon nan aksyon
sivil.Humeur kapab
apiye yon konklizyon sou fè ki
satisfè kondisyon ki legal ki tabli nan 443.151 (4) (b) 5.
Lwa Florid yo; referans ki pi wo a. pi wo a lwa eta yo ki
referans humeur gen dwa pou itilize pou objektif la pou
suplementing oubyen eksplike lòt prèv oswa nan apiye
yon konklizyon si li ta admisib sou plis pase yon
objeksyon nan aksyon sivil. malgre, s. 120.57 (1) (c)
humeur gen dwa sipòte yon reyalite si:
1) pati a kont moun li se ofri a gen yon opòtinite ki
rezonab yo revize sa yo prèv anvan odyans la; ak 2) abit apèl la oswa depite espesyal detèmine apre
konsidere tout reyalite ak sikonstans ke prèv la se fyab
epi proban e ke enterè yo sou jistis ki pi bon te sèvi pa
admisyon li nan prèv.
Si prèv humeur a pa satisfè kondisyon legal yo a pase
prèv la gen dwa kalifye kòm yon ekzanpsyon anba règ la
humeur (gade, 90 chapit F. S) yon anplwayè ki dwe apiye
sou dosye biznis ta dwe bay yon temwen ki ka temwaye
kijan dosye yo te prepare ak garan pou otantisite yo. yon
fwa odyans la
adisyonèl.
fèmen, yo
pa aksepte
okenn prèv
12. ÈSKE SE POU MWEN TA ANPLWAYE YON
AVOKA?
Pwofesyonèl reprezantasyon pa nesesè, epi pi fò moun
reprezante tèt yo nan odyans chomaj la. ou gen dwa gen
reprezantasyon yon avoka oswa yon reprezantan ki gen
otorizasyon nan depans pwòp ou . frè pou reprezante yon
demandè dwe apwouve pa abit apèl la, men peye l se
moun kap fè reklamasyon an. reprezantasyon legal gen
dwa disponib atravè yon biwo èd legal nan redwi oswa
pa koute moun kap fè reklamasyon pou peye anpil lajan.
pou imformation sou pran yon avoka gratis kontakte
Florida nan nimewo Bawo Associetion: 1800 342 8011.
Si wap pran yon avoka oswa ou otorize yon moun pou
reprezante w, bay non moun nan , adrès, ak nimewo
telefòn nan biwo Apèl la asire tout avi yo voye bay moun
nan..
13. E SI MWEN BEZWEN YON ENTÈPRÈT?
Odyans lan pral nan lang angle. tradiksyon yo pral fè
aranjman pou moun kap fè reklamasyon ki endike yon
lang prensipal se lòt pase angle lè ou te aplike pou
benefis yo. si se yon tradiktè ki nesesè epi avi odyans lan
pa endike te gen yon tradiktè ki ranje. fe grefye a
kontakte yon fwa epi mande ki lang ki nesesè, se konsa
aranjman tradiksyon dwe fèt. nimewo telefòn grefye a
sou avi odyans.
14. KILÈS POU MWEN TA KONTAKTE POU
ENFÒMASYON?
Se adrès, telefòn ak nimewo faks nan biwo apèl la kote
ka w la asiyen yo montre sou avi a nan seyans telefòn lan,
osi byen ke non grefye depite ki dwe kontakte oswa
resevwa enfòmasyon. yon lis konplè sou Apèl biwo ale
nan dènye paj la nan ti liv la. Enkli nimero dosye a oswa
nimewo sosyal sekirite demandè a sou tout korespondans
yo.
15. KISA PWOSEDI POU PWOSÈ-YO YE?
Abit apèl la asiyen nan ka sa-a pral:
A. jwenn permision pou enrejistre chak patisipan epi
elektwonikman enrejistre odyans lan.
B. esplike pwoblèm yo, bi pou seyans lan, lòd temwayaj
ak pwosedi;
C. Idantifye detèminasyon an sou apèl la , epi fè konnen
ka-a wap pale a.
D. Mete tout temwen sèmante oubyen afime ;
yon lòd ekri npou tout pati yo. Si ou pa t 'ale nan jijman
an pou yon bon rezon epi ou resevwa yon desizyon
kontrè. al gade nan seksyon 17 pou jwenn enfòmasyon
pou mande yon odyans nouvo.
E. Kesyon pati yo ak temwen yo pran enfòmasyon ;
F. Ede pati le yap kesyone temwen yo ; epi
G. Detèmine si temwayaj ak dokiman yo ofri
resevwa epi konsidere.
ka
16. KOUMAN POU MWEN KNNEN DESIZYON
AN AP SAN PATIPRI?
Abit apèl oblije selon lalwa san patipri epi bay yon
desizyon ki baze sou prèv konpetan. abit apèl la
responsab pou fè yon odisyon san patipri, kesyone
temwen yo, epi pou pwoteje dwa debaz yo nan chak pati.
Abit apèl la pa kapab diskite ka a ak nenpòt ki pati anvan
oswa apre odyans lan.
17. E SI MWEN RATE ODYANS LA?
Si ou te manke yon odyans ou dwe fè egzèsis diligence
pou mande relouvri. nenpòt ki demann pou revisions
dwe depoze sou entènèt la nan www.floridajobs.org.
oswa voye pa lapòs oswa fakse yon demann alekri nan
adrès sa a oswa nimewo faks sou avi a odyans lan oswa
desizyon. pa gen okenn lòt metòd ki otorize. enkli
nimewo dosye a oswa nimewo sosyal demandè a ak pou
ki rezon li pa ale . sèlman konvenkan ak nesesè pou
bezwen rezon konstitye yon bon kòz. si se yon demann
revisions yo akòde ou dwe prezante prèv nan bon kòz nan
odyans la ak montre nouvo diligence n ap eseye ordonne
orè ou oswa ap mande pou ranvwaye li , si bon kòz se pa
sa yo montre, yo pral pran desizyon kite anvan.
18. KI LÈ MAP JWENN YON DESIZYON?
yon desizyon dwe poste voye bay tout pati yo pi vit ke
posib apre odyans la. Desizyon an ap gen ladan
konstatasyon sa ki te reyalite, konklizyon lalwa yo ak
rezilta yo. ki pral afime oswa ranvèse oswa modifye
detèminasyon an oswa rejte apèl la.
19. E SI MWEN PA DAKO AVÈK DESIZYON AN?
Si ou pa dakò avèk desizyon an , ou ka mande pou yon
revizyon nan
retounen travay Asistans Apèl la
enstriksyon pou mande pou revize yo sou desizyon an.
Nenpòt demann pou revizyon dwe depoze nan yon
peryòd 20 jou kalandriye apre desizyon an te poste.
retounen travay Asistans Apèl Komisyon a pa pral fè yon
lòt odisyon. desizyon li pran an dwe baze sou temwayaj
ak lòt prèv yo prezante yo bay abit la ak ki jan abit la te
itilize prèv ki rive nan yon decision. poutet sa , prezante
tout prèv ou nan odyans la trè enpòtan. sou ranpli revize
li yo. retounen travay Asistans Apèl Komisyon ap poste
20. DOSYE-A KA, KONFIDANSYEL?
Non, eksepte pou nimewo sekirite sosyal demandè a la,
enfòmasyon fè apèl kont becames dosye piblik lè se
odyans la konvoke.
21. KI KOTE MWEN KA JWENN PLIS
ENFOMASYON?
Ka Apèl enfòmasyon, ki gen ladan lyen ki mennen nan
Lwa ak Règleman Kòd Administratif, dwe chita sou sit
entènèt nou an nan www.floridajobs.org nan chwazi
retounen travay Asistans Apèl Enfòmasyon oswa
nan www.floridajobs.org pa chwazi Resevwa Lòt
Enfòmasyon sou UC. enfòmasyon sou Asistans Chomay
apré Siklòn, TRA, ak lòt pwogram federal konpansasyon
alokasyon chomaj yo ki sitiye sou entènèt la
nan www.doleta.gov. Ka enfòmasyon sou reklame semèn
alokasyon chomaj yo pandan yon apèl an annatant yo ki
sitiye nan chwazi Reklame Semèn ou sou sit wèb nou an
nan www.floridajobs.org.
Men adrès, nimewo telefòn ak nimewo faks Biwo
Apèl yo:
South Florida Appeals Office
PO Box 8697
Fort Lauderdale Florida 33310-8697
Telefòn: 954/535-5205 Faks: 954/497-1597
Jacksonville Appeals Office
215 Market Street, Suite 240
Jacksonville, Florida 32202-2850
Telefòn: 904/359-6825 Faks: 904/798-4238
Tallahassee Appeals District
Caldwell Building MSC 347
107 East Madison Street
Tallahassee, Florida 32399-4143
Telefòn: 850/921-3262 Faks: 850/921-3219
Winewood Appeals Office
Caldwell Building MSC 350WD
Phone: 850/617-0575 Fax: 850/617-0613
TCHEKE SOU AVI PWOSÈ-A POU
EKZAKTEMAN KI KOTE LAP FÈT
WÈ
Dedomajman pou Chomaj
Enfòmasyon Apèl
Enpòtan - Li enfòmasyon sa a Kounye-a
Papye sa-a se pou enfòmasyon sèlman epi li pa gen tout
efè plen de lalwa osinon règ yo.
Ti liv sa a eksplike pwosedi yo nan tribinal pou pwosè
sou konpansasyon pou chomaj epi kouman pou prepare
pou pwosè an. Si w gen kesyon adisyonèl apre ou fin li
ti liv la, ou pouvwa kontakte biwo grefye a nan nimewo
telefòn ki site nan avi a nan pwosè, oswa tcheke sit
entènèt nou an nan www.floridajobs.org. Si ou se yon
aplikan, epi ou ap toujou travay, kontinye reklame
semèn ou an jan li te planifye, pandan yon pwosesis
apèl yo annatant. Si w ap resevwa yon desizyon
favorab, yo pral peye benefis pou semenn reklame
kòrèkteman yo sèlman.
Parèt sou tan pou odyans lan. Si w resevwa yon Avi
pou Seyans telefòn, oswa si ou gen te pwograme yo
patisipe atravè telefòn, li avèk atansyon Seksyon 16 ki
te gen enstriksyon espesyal pou odyans telefòn. Tcheke
ki se nimewo telefòn ou kòrèkteman ekri sou Avi a nan
seyans lan telefòn e kontakte Grefye a Adjwen si ou yo ta
dwe rele nan yon lòt nimewo telefòn oswa si w pa te
resevwa yon apèl telefòn dis minit apre lè ki nan orè
kòmanse pou odyans lan.
Si ou pa pale oswa li angle byen, mande li tradui
enfòmasyon sa a enpòtan imedyatman.
Selon Lwa ki konsène Ameriken ki gen Andikap
la (Americans with Disabilities Act) moun ki
bezwen akomodasyon espesyal pou patisipe nan
yon pwosè ka kontakte grefye a nan nimewo ki
make sou Avi Pwosè-a omwen 5 jou anvan pwosèa oswa rele nan Sèvis Repondè Florid la nan 1800-955-8770.
Depatman EkonomikOpòtinite se yon ajans opòtinite
egal ki ofri tout moun benefis yo pou patisipe nan
tout pwogram li yo, epi pou chache tout kalite
anplwa san okenn diskriminasyon poutèt ras, koulè,
relijyon, sèks, nasyonalite, laj, anpèchman oswa
domaj fizik, oswa lòt bagay ki pa merite anyen lè
wap konsidere anplwa.
DEO Form UCA Bulletin 6C (Rev 6/12)
Laat deze belangrijke informatie vertalen onmiddellijk.
Tenha esta informação importante traduzida imediatamente.
Ha denne viktige informasjonen som oversatt straks.
1. WHY IS THIS HEARING IMPORTANT?
The decision from this hearing will replace the
determination that was appealed. Only one hearing level
is provided by law. To protect your rights, you must
participate even if the other party filed the appeal. If you
cannot attend as scheduled, immediately follow the
instructions in Section 9 to request rescheduling.
Otherwise, you may receive an unfavorable decision. A
claimant who receives an unfavorable decision will have
to repay benefits that should not have been paid. An
employer who receives an unfavorable decision may
receive benefit charges that increase the employer’s tax
rate or require reimbursement to the trust fund.
Be prepared to present evidence on all issues listed
on the Notice of Hearing. The decision will be based
only on evidence presented at the hearing. A second
appeal level exists, but includes only a review of the
existing record, not a new hearing.
2. WHY WAS A HEARING SCHEDULED?
A hearing was scheduled because an Department
determination was appealed. Participating in the hearing
is important, even if the other party filed the appeal.
3. WHAT HAPPENS IF I DON’T PARTICIPATE?
If the party who filed the appeal participates, a hearing
will be held. The decision will be based on the evidence
presented. If you don’t participate, your evidence will
not be considered. If you filed the appeal and do not
participate, your case will be dismissed.
4. WHAT ARE MY RIGHTS AT THE HEARING?
As a party, you have the right to:
A. Testify in your own behalf;
B. Present documents and other evidence;
C. Question your own witnesses;
D. Question the opposing party’s witnesses;
E. Examine and object to evidence presented;
F. Explain or rebut evidence presented; and
G. Make a closing statement at the end of the hearing.
5. HOW CAN I ARRANGE FOR WITNESSES?
Contact and ask the witness to testify. The best witness
is one with personal knowledge of the facts. A witness
who was present at an event is much better than one who
was told about it by someone else. If possible, you and
your witness(es) should be at the same location for the
hearing. If a witness cannot be at your location and must
be contacted at a different telephone number, provide the
witness’ name and telephone number to the deputy clerk
whose name and telephone number appear on the Notice
of Telephone Hearing. Instruct the witness to be
available at the scheduled hearing time and to remain
available until dismissed by you or the appeals referee
If a witness refuses to testify voluntarily, a subpoena
can be requested by writing to the address on the Notice
of Hearing. Mail or fax the request as soon as possible,
so the subpoena can be served before the hearing.
Include the case docket number; the witness’ name,
address, and telephone number (if available), as well as a
detailed description of any document(s) the witness
should furnish for the hearing.
6. HOW DO I PROVE I LOOKED FOR WORK?
If the issue is whether you were able and available for
work, send a copy of your work search contact sheets to
the Appeals Office before the hearing. Include each job
contact date and method, as well as each employer
contact’s name and address.
7. HOW DO I SHOW I FILED MY APPEAL ON TIME?
If the appeal does not appear to have been filed within
the time allowed by law, the referee will first take
evidence on the timeliness of the appeal. If timeliness is
listed as an issue, the person who filed the appeal would
be an important witness. The case will be dismissed
without competent evidence of timely filing.
8. CAN I WITHDRAW MY APPEAL?
The appellant may withdraw an appeal by mail or fax to
the Appeals Office address or fax number on the Notice
of Hearing or to: Office of Appeals; MSC 347; 107 E
Madison Street; Tallahassee FL 32399-4143. Include the
claimant's Social Security number and docket number. In
most situations, a withdrawn appeal cannot be reopened.
9. CAN I REQUEST A POSTPONEMENT?
A postponement may be requested if there is a
compelling reason why you cannot participate as
scheduled. The request can be made in writing before the
hearing or on the record during the hearing. Include the
reason you cannot participate and what, if any, attempts
you made to re-arrange your schedule so you could
participate. The referee will let you know in writing if
the request is granted. If a written reply is not received,
assume the request was denied. Be available for the
hearing and prepared to present your case.
10. HOW CAN I GET A COPY OF THE CASE FILE?
12. SHOULD I HIRE AN ATTORNEY?
Copies of all documents available to the referee are
enclosed with the Notice of Telephone Hearing. Review
and have these documents with you during the hearing.
Professional representation is not required and most
people represent themselves at unemployment hearings.
You have the right to be represented by an attorney or
authorized representative at your own expense. Fees for
representing a claimant must be approved by the appeals
referee, but paid by the claimant. Legal representation
may be available through a local Legal Aid Office at
reduced or no cost for low-income claimants. For
information about hiring an attorney, contact the Florida
Bar Association toll-free at 1-800-342-8011. If you hire
an attorney or authorize someone to represent you,
provide the person’s name, address, and telephone
number to the Appeals Office to ensure all notices are
sent to that person.
11. WHAT EVIDENCE SHOULD I PROVIDE?
The best evidence is testimony from a person who was
present at an event and can answer specific questions
about what happened. Claimants almost always have
first-hand knowledge of the events. Employers should
choose witnesses carefully to ensure competent evidence
is presented.
If a document you previously submitted is not
included with the hearing notice, you must send
another copy to the hearing officer and all other
addresses on the Notice of Telephone Hearing in
order to have the document considered. To have
documents considered, mail, fax, or deliver a copy of
each to the Appeals Office and all addresses on the
hearing notice, before the hearing date. Only documents
received by all parties can be considered, unless the
right to view the documents is waived. All evidence
becomes public record when the hearing is convened.
Most documents and affidavits are hearsay and
may be used for the purpose of supplementing or
explaining other evidence or to support a finding if it
would be admissible over an ojection in civil actions.
Hearsay may support a finding of fact if it meets the
statutory requirements set forth in 443.151(4)(b)5,
Florida Statutes. The above referenced statute states that
hearsay evidence may be used for the purpose of
supplementing or explaining other evidence, or to support a
finding if it would be admissible over objection in civil
actions. Notwithstanding s. 120.57(1)(c), hearsay evidence
may support a finding of fact if:
1.
The party against whom it is offered has a
reasonable opportunity to review such evidence prior to the
hearing; and
2.
The appeals referee or special deputy determines,
after considering all relevant facts and circumstances, that the
evidence is trustworthy and probative and that the interests of
justice are best served by its admission into evidence.
If the hearsay evidence does not meet the statutory
requirements, then the evidence may qualify as an
exception under the hearsay rule, (see Chapter 90, F.S.).
An employer who must rely on business records should
provide a witness who can testify how the records were
prepared and vouch for their authenticity. Once the
hearing is closed, no additional evidence will be
accepted.
13. WHAT IF I NEED A TRANSLATOR?
The hearing will be in English. Translation will be
arranged for claimants who indicate a primary language
other than English when filing for benefits. If a translator
is needed and the Notice of Hearing does not indicate a
translator was arranged, have the deputy clerk contacted
at once to advise what language is needed so translation
arrangements can be made. The deputy clerk’s telephone
number is on the Notice of Hearing.
14. WHAT IF I NEED MORE INFORMATION?
The address, telephone, and fax numbers of the Appeals
Office where your case was assigned is shown on the
Notice of Telephone Hearing, as well as the name of the
deputy clerk who should be contacted to provide or
receive information. A complete list of Appeals Offices
is shown on the last page of this pamphlet. Include the
docket number or claimant’s social security number on
all correspondence.
15. WHAT ARE THE HEARING PROCEDURES?
The appeals referee assigned to the case will:
A. Obtain permission to record from each participant
and electronically record the hearing.
B. Explain the issues, purpose of the hearing, order of
testimony, and other procedures;
C. Identify the determination on appeal and make
known the contents of the case file;
D. Place all witnesses under oath or affirmation;
E. Question parties and witnesses to obtain the facts;
F. Assist parties as they question witnesses; and
G. Determine if testimony and documents being offered
should be received and considered.
DEO Form UCA Bulletin 6E (Rev. 4/12)
16. HOW DO I KNOW THE DECISION WILL BE FAIR?
The appeals referee is required by law to be impartial
and issue a decision based on competent evidence. The
appeals referee is responsible for conducting a fair
hearing, questioning the witnesses, and protecting the
basic rights of each party. The appeals referee cannot
discuss the case with any party before or after the
hearing.
17. WHAT IF I MISSED THE HEARING?
If you missed a hearing you must exercise due
diligence in requesting re-opening. Any request for
rehearing must be filed on the Internet at
www.floridajobs.org, or by mailing or faxing a written
request to the address or fax number on the Notice of
Hearing or Decision. No other methods are permitted.
Include the Docket Number or the claimant’s social
security number and the reason for not attending. Only
compelling and necessary reasons constitute good
cause. If a rehearing request is granted, you must
present evidence of good cause at the new hearing and
show due diligence in trying to re-arrange your schedule
or requesting postponement. If good cause is not shown,
the prior decision will be reinstated.
18. WHEN WILL I RECEIVE A DECISION?
A decision will be mailed to all parties as soon as
possible after the hearing. The decision will include
findings of fact, conclusions of law, and the result,
which will affirm, reverse, or modify the determination
or dismiss the appeal.
19. WHAT IF I DISAGREE WITH THE DECISION?
If you disagree with the decision, you can request
review by the Reemployment Assistance Appeals
Commission. Instructions for requesting review are on
the decision. Any request for review must be filed
within 20 calendar days after the decision was
mailed. The Reemployment Assistance Appeals
Commission will not hold another hearing; its decision
will be based on the testimony and other evidence
presented to the referee and how the referee used that
evidence to reach a decision. Therefore, presenting all of
your evidence at the hearing is very important. Upon
completing its review, the Reemployment Assistance
Appeals Commission will mail a written order to all
parties.
If you did not attend the hearing for good cause
and received an adverse decision, refer to Section 17 for
information about requesting a new hearing.
No, except for the claimant’s social security number,
appeal information becomes public record when the
hearing is convened.
Appeals Office
Numbers:
Addresses,
Phone
&
Fax
21. WHERE CAN I FIND MORE INFORMATION?
Appeals information, including links to statutes and
Administrative Code Rules, can be located on our
www.floridajobs.org
by
choosing
website
at
Reemployment Assistance Appeals Information or at
www.floridajobs.org by choosing Receive Other UC
Information. Information about Disaster Unemployment
Assistance, TRA, and other federal unemployment
compensation programs can be located on the Internet at
www.doleta.gov. Information about claiming weeks of
unemployment while an appeal is pending can be
located by choosing Claim Your Weeks on our website
at www.floridajobs.org.
In accordance with the Americans with Disabilities
Act, persons needing special accommodation to
participate in the hearing may contact the deputy
clerk at the number shown on the Notice of Hearing
at least 5 days before the hearing or via Florida
Relay Service at 1-800-955-8770.
Reemployment Assistance is an equal opportunity
program of the Department of Economic Opportunity.
Auxiliary aids and services are available upon request to
individuals with disabilities.
South Florida Appeals Office and Ft Lauderdale
Appeals Office
PO Box 8697
Phone: 954/535-5205 Fax: 954/497-1597
Phone: 904/359-6825 Fax: 904/798-4238
Tallahassee Appeals Office
Phone: 850/921-3262 Fax: 850/921-3219
Phone: 850/617-0575 Fax: 850/617-0613
THE APPEALS OFFICE ADDRESS, PHONE AND FAX
NUMBERS FOR YOUR CASE ARE ON THE NOTICE OF
TELEPHONE HEARING. IF YOU ARE SCHEDULED TO
APPEAR IN PERSON, THE LOCATION IS ON THE
NOTICE OF HEARING.
This pamphlet is for informational purposes only and does not
have the full effect of law and/or regulations.
This pamphlet provides a summary of general
information about reemployment assistance appeals
and how to prepare for your hearing. The hearing
notice may contain specific instructions and
information. Failure to comply with those instructions
may cause a delay in resolving the case or exclusion of
evidence you wish to present.
If you have questions after reading the pamphlet, call
the deputy clerk at the telephone number on the Notice
of Telephone Hearing or check our website at
www.floridajobs.org. If you are an unemployed
claimant, continue claiming weeks as scheduled while
any appeal is pending. If you receive a favorable
decision, benefits will only be paid for properly claimed
weeks.
Be ready on time to receive the hearing officer’s
telephone call. If you do not receive a call within ten
minutes after the scheduled hearing time, contact the
deputy clerk whose telephone number appears on
the Notice of Telephone Hearing. Employers must
provide the name and number of the person to be
telephoned for the hearing. Claimants will be called at
the telephone number shown on the hearing notice
unless a different number is provided before the hearing.
It is each party’s responsibility to remove any callblocking service that would prevent the telephone call
from reaching you. Any party scheduled to appear in
person, will receive special supplemental instructions.
If you do not speak or read English well, have this important
information translated immediately.
Tenga esta información importante traducida inmediatamente.
Avere queste informazioni importanti tradotte immediatamente.
Avoir cette information importante traduite immédiatement.
Tradui information importan sa a immediatemant.
Lassen Sie diese wichtigen Informationen übersetzen sofort.
20. WILL THE CASE RECORD BE CONFIDENTIAL?
DEO Form UCA Bulletin 6E (Rev. 4/12)
1. ¿POR QUÉ ES IMPORTANTE LA AUDIENCIA?
La decisión de esta audiencia reemplazará la determinación
que fue apelada. La ley solamente provee un nivel de
audiencia. Para proteger sus derechos, debe de participar
aunque haya sido la otra parte la que haya apelado. Si no va
a poder asistir, siga inmediatamente las instrucciones de la
Sección 9 para cambiar la fecha. Si no lo hace así, podría
recibir una decisión adversa. Un reclamante que recibe una
decisión adversa tendrá que devolver los beneficios que no
le deberían de haber sido pagados. Un empleador que recibe
una decisión adversa, puede recibir cargos de beneficio los
cuales aumentaran su tasa de impuestos o se podrá exigir un
reembolso a los fondos fiduciarios .
Aviso de Audiencia. Informe al testigo que tendrá de estar
disponible durante el horario programado para la audiencia y
que tendrá mantenerse disponible hasta que usted o el árbitro lo
despida.
Si un testigo se niega a aparecer voluntariamente, se puede
solicitar una citación escribiendo a la dirección en el Aviso de
Audiencia. Escriba o envíe la petición por fax cuanto antes,
para que el testigo tenga tiempo para prepararse. La petición
para una citación debe de contener:
A. El número de expediente del caso;
B. Los nombres y direcciones de los testigos;
C. La hora/lugar en la que los testigos han de aparecer;
D. Una descripción detallada de cualquier documento que
los testigos deben de traer.
Esté listo para presentar evidencia sobre todos los asuntos
que aparecen en el Aviso de Audiencia. La decisión será
basada únicamente en evidencia presentada en la audiencia.
Existe un segundo nivel de apelación, pero consiste
solamente en una revisión del acta ya existente, no en una
nueva audiencia.
6. ¿CÓMO PUEDO PROBAR QUE YO ESTABA DISPONIBLE
PARA TRABAJAR?
2. ¿POR QUÉ SE FIJÓ LA FECHA PARA UNA AUDIENCIA?
7. ¿CÓMO PUEDO PROBAR QUE MI APELACIÓN FUE
PRESENTADA A TIEMPO?
Si la apelación no parece haber sido presentada dentro del
plazo permitido por la ley, el árbitro tomará primero la
evidencia de si la apelación fue presentada dentro del plazo.
Si una de las cuestiones listadas es si la apelación fue
presentada dentro del plazo, la persona que presentó la
apelación será un testigo importante. El caso será
desestimado si no hay evidencia competente de que se
presentó dentro del plazo.
Sí la parte que presentó la apelación asiste, la audiencia tomara
lugar. La decisión será basada en la evidencia presentada. Si
usted no participa de la audiencia, su evidencia no será
considerada. Si presentó la apelación y no participas de la
audiencia, el caso será descartado.
3. ¿TENDRÁ LUGAR LA AUDIENCIA SI NO ESTOY AHÍ?
Sí, si la parte que presentó la apelación asiste. La decisión
será basada en la evidencia presentada. Si Ud. no está allí,
su evidencia no será considerada. Si presentó la apelación y
no asiste, el caso será desestimado.
4. ¿CUÁLES SON MIS DERECHOS EN LA AUDIENCIA?
Como una de las partes, usted tiene el derecho a:
A. Testificar;
B. Presentar documentos y evidencia adicional;
C. Interrogar sus propios testigos;
D. Interrogar a la parte opuesta y a los testigos;
E. Examinar y declarar objeciones a la evidencia;
F. Explicar o refutar evidencia que ha sido presentada; y
G. Tomar una declaración final al concluir la audiencia.
5. ¿CÓMO PUEDO DISPONER DE TESTIGOS?
Contacte y pida a los testigos que asistan y testifiquen. El mejor
testigo es uno que tenga conocimiento personal de los hechos.
Un testigo que estuvo presente cuando un hecho ocurrió es
mucho mejor que uno a quien alguien contó algo. Si es posible
sería mejor que usted y sus testigos estén en el mismo lugar. Si
un testigo no puede estar en el mismo lugar que usted y
tendremos que llamar a un número de teléfono diferente al
suyo, provea el nombre del testigo y el número de teléfono a la
oficinista, cuyo nombre y número de teléfono aparece en el
Si el tema es si usted está capaz y disponible para trabajar, envié
una copia de su registro de búsqueda de trabajo a la Oficina de
Apelaciones para la audiencia. Incluya cada fecha de contacto
para cada trabajo, y el método, así como el nombre y dirección
del contacto de cada empleador.
8. ¿QUÉ SUCEDE SI CAMBIO DE OPINIÓN SOBRE APELAR?
La parte que apela puede retirar la apelación por correo/fax
a la dirección o no. de fax de la Oficina de Apelación en el
Aviso de Audiencia o a: Office of Appeals; MSC 347; 107 E
Madison Street; Tallahassee FL 32399-4143. Incluya el
número de Seguridad Social del reclamante y el número de
expediente. En la mayoría de los casos, una apelación
retirada no puede ser reabierta.
9. PUEDO SOLICITAR UNA POSTERGACION ?
Usted puede pedir un postergación si existe una razón que le
impide participar de la audiencia. La postergación puede ser
pedida por escrito antes de la audiencia, o en la audiencia.
Incluya la razón por la cual no puede participar y qué
arreglos has hecho para poder asistir a la audiencia. El
árbitro considerará cada solicitud y le hará saber por escrito
si la solicitud ha sido otorgada. Si una respuesta no es
recibida, suponga que la solicitud no ha sido otorgada.
Esté presente en la audiencia listo/a para presentar su caso.
10. ¿CÓMO PUEDO OBTENER UNA COPIA DEL
EXPEDIENTE?
Copias de todos los documentos disponibles para el árbitro
serán enviados juntos con el Aviso de Audiencia. Repase y
tenga estos documentos con usted para la audiencia.
11. ¿QUE TIPO DE EVIDENCIA DEBO APORTAR?
El mejor tipo de evidencia es el testimonio de alguien que
estuvo presente cuando sucedió el evento, y puede responder a
preguntas específicas sobre lo que sucedió. Los reclamantes casi
siempre tienen conocimiento de primera mano de los asuntos en
cuestión. Los empleadores han de elegir testigos
cuidadosamente para asegurar que la evidencia presentada sea
competente.
Si un documento el cual usted previamente nos envió no fue
incluido con el aviso de audiencia, envíe otra copia al árbitro
de apelaciones y a todas las partes que aparecen en el Aviso
de Audiencia Telefónico para que tal documento sea
considerado. Para que documentos sean considerados, puedes
enviarlos por fax, correo o enviar copias de cada documento a la
Oficina de Apelaciones y todas las direcciones que aparecen en
el aviso de audiencia, antes de la fecha de la audiencia.
Solamente documentos recibidos por todas las partes
pueden ser considerados, a no ser que el derecho de
examinar los documentos sea renunciada. Toda evidencia
llega a ser publica cuando se convoca la audiencia.
La mayoría de documentos y declaraciones escritas son
rumores y pueden ser utilizados con el propósito de
suplementar o explicar otra evidencia o apoyar
determinaciones de una cuestión de hechos si es que sería
admisible después de una objeción en una acción civil.
Testimonio de rumor puede ser utilizado para apoyar hechos
si cumple con los requisitos establecidos en 443.151(4)(b)5,
Estatutos de la Florida. El estatuto mencionado declara que
evidencia de rumor puede ser utilizado para suplir o explicar
otra evidencia, o para apoyar determinaciones de una
cuestión de hechos si sería admisible en una acción civil. No
obstante, 120.57(1)(c), evidencia de rumor puede apoyar
determinaciones de una cuestión de hechos si:
1). La parte contra quien es ofrecido tiene tiempo razonable
para examinar la evidencia antes de la audiencia; y
2). Si el arbitro de apelaciones determina, después de
considerar todos los hechos y circunstancias relevantes, que
la evidencia es digna de confianza y probatorio y los
intereses de la justicia son servido por introducirlo como
evidencia.
Si el testimonio de rumor no cumple con los requisitos de
los estatutos, en tal caso la evidencia puede calificar bajo la
ley de rumor (Vea el Capitulo 90, F.S.). Un empleador que
utiliza los archivos del negocio necesita proveer un testigo
que pueda testificar en como los archivos fueron preparados
y responder por su autenticidad. Cuando se termine la
audiencia, evidencia adicional no será aceptada.
12. ¿DEBO DE CONTRATAR A UN ABOGADO?
Representación profesional no es requerida. La mayoría de
las personas se representan a sí mismas en audiencias de
desempleo. Usted tiene el derecho a ser representado por un
abogado o representante autorizado a su propia costa.
Honorarios de representación de un reclamante deben ser
aprobados por el árbitro de apelación, pero pagados por el
reclamante. Representación legal puede ser disponible a
través de una Oficina de Ayuda Legal local a costo reducido
o gratis para reclamantes con ingresos bajos. Para
información sobre la contratación de un abogado, póngase
en contacto con la Asociación de Abogacía de Florida gratis
al 1-800-342-8011. Si contrata a un abogado o autoriza a
alguien que le represente, provea a la Oficina de
Apelaciones con el nombre, dirección, y número de teléfono
por escrito, de esa forma podremos asegurarnos de enviar
los avisos a esa persona.
13. ¿Y SI NECESITO UN TRADUCTOR?
La audiencia tendrá lugar en inglés. Traducción será
concertada para reclamantes que indiquen una lengua
primaria diferente al inglés cuando cursan su solicitud para
beneficios. Si un traductor es necesario, y el Aviso de
Audiencia no anuncia que la traducción está concertada,
contacte al Subalterno Administrativo inmediatamente para
avisar que lengua se necesita, para que la planificación
pueda ser efectuada. El no. de teléfono del Subalterno
Administrativo se encuentra en el Aviso de Audiencia.
14. ¿A QUIÉN CONTACTO PARA MÁS INFORMACIÓN?
La dirección, teléfono, y no. de fax de la Oficina de
Apelaciones donde su caso fue asignado, aparece en el
Aviso de Audiencia, junto con el nombre del Subalterno
Administrativo que debe ser contactado para proveer o
recibir información. Vea la última sección de este folleto
para una lista completa de las Oficinas de Apelaciones.
Incluya el no. de expediente o el no. de seguro social del
reclamante en toda correspondencia.
15. ¿CUÁL ES EL PROCEDIMIENTO DE LA AUDIENCIA?
El árbitro de apelaciones:
A. Explicará los asuntos, el propósito de la audiencia, el
orden del testimonio, y otros trámites;
B. Identificará la determinación apelada y hará saber el
contenido del expediente del caso;
C. Pondrá a todos los testigos bajo juramento o
afirmación;
D. Cuestionará a las partes y testigos para obtener los
hechos;
E. Asistirá a las partes mientras cuestionan los testigos;
F. Determinará si el testimonio y los documentos
ofrecidos deben ser recibidos y considerados.
G. Grabará la audiencia electrónicamente.
16. ¿ COMO SE QUE LA DECISION SERA JUSTA?
La ley requiere que el árbitro de apelaciones sea imparcial,
que dirija una audiencia justa, y que emita una decisión
DEO Form UCA Bulletin 6S (Rev. 05/12)
basada en evidencia competente. El árbitro será responsable
de dirigir una audiencia justa, interrogando todos los
testigos y proteger los derechos básicos de cada parte. El
árbitro de apelaciones no puede discutir el caso con ninguna
de las partes antes o después de la audiencia.
17. ¿Y SI FALTO A LA AUDIENCIA?
Si falto a la audiencia usted tiene que ser diligente y solicitar
una reapertura del caso. Cualquier solicitud para reabrir el caso
tiene que ser hecha por el Internet en www.floridajobs.org, o
por correo o el número de fax que aparece en el Aviso de
Audiencia o Decisión. Ninguna otro método es permitido.
Incluya el numero de ficha o el número de seguro social del
reclamante y la razón por no estar presente en la audiencia.
Solamente razones apremiantes y necesarias se considerada
buena causa. Si una solicitud para una nueva audiencia es
aceptada, tienes que presentar buena causa en la nueva
audiencia y mostrar diligencia in tratar de programarse para
estar presente en la audiencia o al solicitar una postergación de
la audiencia. Si buena causa no es establecida, la decisión previa
continuara en vigor..
18. ¿CUÁNDO RECIBIRÉ LA DECISIÓN?
Le decisión será enviada por correo a todas las partes lo más
antes posible después de la audiencia. La decisión incluirá
descubrimiento de hechos, conclusiones de la ley, y el
resultado, el cual afirmará, reversará o modificará la
determinación, o desestimará la apelación.
19.¿QUÉ SUCEDE SI NO ESTOY DE ACUERDO CON LA
DECISIÓN?
Si no está de acuerdo con la decisión, puede pedir una revisión
del Comité de Apelaciones Ayuda de Reempleo. La decisión
incluye instrucciones para pedir una revisión. Cualquier
petición para revisión debe de ser registrada dentro de 20
días de calendario después de haberse enviado por correo la
decisión. El Comité de Apelaciones Ayuda de Reempleo no
tendrá otra audiencia; su decisión será basada en el testimonio y
otra evidencia presentada al árbitro y cómo el árbitro usó esa
evidencia para llegar a una decisión. Por eso es muy importante
el presentar toda la evidencia en la audiencia. Después de haber
completado su revisión, el Comité de Apelaciones Ayuda de
Reempleo enviará una orden por escrito a todas las partes.
Si usted no estuvo presente en la audiencia por buena causa y
recibió una decisión adversa, consulte las instrucciones para
pedir una nueva audiencia en la Sección 17.
20. ¿EL CASO SERA CONFIDENCIAL?
No, con excepción del número de seguro social del
reclamante, información sobre la apelación llega ser
archivos públicos cuando la audiencia termina.
20.¿DÓNDE
PUEDO
ENCONTRAR
INFORMACIÓN?
MÁS
Información sobre Apelaciones para compensación por
desempleo, y enlaces a la Ley de Compensación por
Desempleo, y reglas del Código Administrativo, se encuentran
en nuestra página del web: www.floridajobs.org y escogiendo
Información Ayuda de Reempleo y Apelaciones, o en
www.floridajobs.org escogiendo Recibir otra información
sobre Compensación por desempleo. Información relacionado a
Ayuda de Desempleo por Desastres Naturales, TRA, y otros
programas federales para compensación del desempleo se
pueden encontrar en el Internet en www.doleta.gov.
Información relacionado a reclamo de semanas mientras que
haiga una apelación pendiente se puede encontrar por elegir
Reclame sus semanas en nuestra página en el Internet
www.floridajobs.org.
De acuerdo con el Americans with Disabilities Act, toda
persona que necesite acomodación especial para
participar en la audiencia, puede ponerse en contacto con
el Suplente Administrativo (Deputy Clerk) llamando al
número de teléfono que aparece en el Aviso de Audiencia
(Notice of Hearing), con un mínimo de 5 días de
antelación antes de la audiencia o por el Florida Relay
Service a 1-800-955-8770.
El Departamento de Oportunidad Económica, promueve la
igualdad de oportunidades, ofreciéndole a toda persona el
derecho de participar en cada uno de sus programas y de
competir en todos los niveles de empleo, independientemente
de la raza, color, religión, sexo, origen nacional, edad,
impedimentos físicos u otros factores sin mérito.
Números de Teléfono y Fax y Localización de las Oficinas de
Apelaciones
South Florida Appeals Office
PO Box 8697
Phone: 954/535-5205 Fax: 954/497-1597
Phone: 904/359-6825 Fax: 904/798-4238
Phone: 850/617-0575 Fax: 850/617-0572
Tallahassee Appeals Office
Phone: 850/921-3262 Fax: 850/921-3219
EL LUGAR DONDE SE CELEBRARÁ LA AUDIENCIA
ESTÁ EN EL AVISO DE AUDIENCIA
ESTE FOLLETO ES ÚNICAMENTE DE CARACTER INFORMATIVO Y
NO APLICA EL RIGOR DE LA LEY Y/O LOS REGLAMENTOS.
Apelaciones Ayuda de Reempleo
Información Sobre
Apelaciones
Importante– Leer Immediatamente
Este folleto explica el proceso Apelaciones Ayuda de Reempleo
por desempleo y cómo prepararse para su audiencia. El aviso de
audiencia tendrá instrucciones e información específica. Si no
sigues esas instrucciones puede resultar en la demora de
finalizar su caso o puede resultar en que evidencia que usted
desee presentar sea excluida. Si usted tiene alguna duda
después de leer este folleto, póngase en contacto con la
oficinista, cuyo número de teléfono aparece en el Aviso de
Audiencia, o vaya a nuestra página de Internet:
www.floridajobs.org. Si usted es un reclamante y continúa
todavía desempleado, siga reclamando semanas según el horario
previsto mientras la apelación sigue pendiente. Si recibe una
decisión favorable, los beneficios serán pagados únicamente por
semanas que hayan sido debidamente reclamadas. Este listo a
tiempo para atender la llamada telefónica del árbitro. Si
usted no recibe una llamada telefónica dentro de diez
minutos después de la hora programada para la audiencia
comuníquese con la oficinista, cuyo teléfono aparece en el
Aviso de Audiencia Telefónico. Empleadores deben proveer el
nombre y número de teléfono del individuo que debemos llamar
para la audiencia. Se llamara a los reclamantes al número de
teléfono que aparece en el aviso de audiencia a no ser que se nos
dé un número de teléfono diferente antes de la audiencia. Es la
responsabilidad de todas las partes de remover cualquier
servicio telefónico que impide que nuestra llamada telefónico
sea atendida. Cualquier parte programada para comparecerse en
persona, recibirá instrucciones adicionales.
If you do not speak or read English well, have this important
information translated immediately.
Tenga esta información importante traducida inmediatamente.
Avere queste informazioni importanti tradotte immediatamente.
Avoir cette information importante traduite immédiatement.
Tradui information importan sa a immediatemant.
Lassen Sie diese wichtigen Informationen übersetzen sofort.
DEO Form UCA Bulletin 6S (Rev. 05/12)
1. WHY IS THIS HEARING IMPORTANT?
A hearing was scheduled because a determination issued
by the Department of Revenue was appealed. The Final
Order resulting from this hearing will replace the
determination that was appealed. Only one Department
hearing level is provided by law. To protect your rights,
you should participate even if another party filed the
appeal. If you cannot participate as scheduled,
immediately follow the instructions in Section 9 to
request rescheduling. Otherwise, you may receive an
unfavorable ruling. A claimant who was joined as a
party and receives an unfavorable ruling will have to
repay reemployment assistance benefits that should not
have been received.
Be prepared to present evidence on all issues listed
on the Notice of Telephone Hearing. THE FINAL
ORDER WILL BE BASED ONLY ON EVIDENCE
IN THE HEARING RECORD.
until dismissed by you or the special deputy. A witness
who can give a firsthand account of what happened is
better than one who presents testimony of what was
heard from others.
If you believe a party possesses a document that you
wish to present as part of your case, contact the party
directly and request a copy of the document(s). Upon
receipt, mail a copy to the special deputy and all
addresses shown on the Notice of Telephone Hearing.
Documents or affidavits standing alone are normally
hearsay and insufficient to prove a case, unless it
meets the statutory requirements set forth under
443.151(4)(b)5., Florida Statutes. If you plan to submit
business records in evidence, you should also present a
witness who can verify when and how the records were
prepared and vouch for their authenticity. After the
hearing is closed, the special deputy will not accept
additional documents or evidence.
2. WHO ARE PARTIES TO THE APPEAL?
The parties to a special deputy appeal include the
employing unit (Petitioner), the Department of Economic
Opportunity(Respondent),
represented
by
the
Department of Revenue, and any claimant whose
Reemployment Assistance claim may be affected by the
outcome of the appeal (Joined Party). Others may be
joined as parties as the special deputy deems appropriate.
6. WHAT IF A WITNESS REFUSES TO TESTIFY?
You may request a subpoena for a witness who refuses to
testify voluntarily. If a party refuses your request to
provide a document copy for the hearing, you may
request a subpoena duces tecum for the document. Any
request for subpoena must be delivered to the special
deputy clerk sufficiently in advance of the hearing date
to allow time for the subpoena to be served prior to the
hearing. Include on the written request:
♦The docket number assigned to the case;
♦The name and address of any person to whom a
subpoena is to be issued; and
♦A detailed description of any document(s) to be
furnished by the witness.
3. WHAT WILL HAPPEN IF I DON’T ATTEND A HEARING?
If the Petitioner does not attend the hearing, the special
deputy will recommend that the case be dismissed. If the
Petitioner appears, the hearing will be conducted with
the parties who attend and the result will be based on the
hearing record.
4. WHAT ARE MY RIGHTS AT THE HEARING?
As a party, you have the right to:
A. Testify in your own behalf;
B. Present documents and other pertinent evidence;
C. Arrange for witnesses to testify;
D. Question the other parties and witnesses;
E. Explain or rebut evidence;
F. Make a statement at the end of the hearing;
G. Examine and object to evidence presented.
5. HOW CAN I ARRANGE FOR WITNESSES?
Notify the witness and arrange for the witness to be
present at your location for the hearing. If the witness
cannot be present at your location, provide to the special
deputy clerk the name of the witness and the telephone
number where the witness agreed to be reached for the
hearing. Advise the witness to be available 10 minutes
prior to the scheduled hearing time and remain available
7. HOW CAN I PROVE MY APPEAL WAS FILED ON TIME?
The appeal must be filed within the time shown on the
determination. If the last day to appeal is a Saturday,
Sunday, or holiday as specified in Section 110.117,
Florida Statutes, the appeal time is extended to the next
working day (Monday through Friday). If listed as an
issue on the hearing notice, timeliness of the appeal will
be the first issue addressed by the special deputy. If the
issue of timeliness is resolved unfavorably to the
Petitioner, the special deputy will adjourn the hearing
and recommend that the appeal be dismissed for lack of
jurisdiction. If the appeal is considered timely, the
special deputy will complete the hearing and address the
remaining issues. When timeliness of the appeal is an
issue, the person who actually filed the appeal is an
important witness. The case will be dismissed without
competent evidence of timely filing.
8. WHAT IF I WISH TO WITHDRAW MY APPEAL?
The Petitioner may withdraw an appeal by mail or fax to
the Appeals Office address or fax number on the Notice
of Telephone Hearing or to: Office of Appeals; MSC
347; 107 E Madison Street; Tallahassee FL 32399-4143.
(Fax: 850-921-3925) Include the docket number and
employer account number on the withdrawal request. In
most situations, a withdrawn appeal cannot be reopened.
9. WHAT IF I CAN’T MAKE IT TO THE HEARING?
The special deputy will postpone or continue a hearing
only for good cause and only if requested in writing
prior to the hearing or orally at the hearing. Include
the reason for requesting a different hearing date. If
requested prior to the hearing, the special deputy will
consider the request and immediately notify the parties in
writing of the decision. Unless the request is granted,
the hearing will proceed as scheduled. If you request a
continuance prior to the hearing but do not receive a
reply by the date of the hearing, attend the hearing and
be prepared to present your case.
A party who was unable to participate in the hearing
for good cause may make written application for
rehearing, stating in detail the reason for not
participating. If good cause is alleged and the request is
filed within fifteen (15) days of the mailing of the
Recommended Order, the special deputy will rescind the
Recommended Order and reopen the appeal. At the
rescheduled hearing, the party will be required to present
evidence to establish good cause for not attending the
previous hearing. Good cause is restricted to reasons of a
compelling and necessary nature, not of convenience. If
good cause is not found, the special deputy will adjourn
the hearing and reinstate the Recommended Order.
10. WHAT TYPE OF EVIDENCE SHOULD I PROVIDE?
The best type of evidence is testimony from someone
who was present when an event occurred and can
answer specific questions about what happened.
Choose witnesses carefully to ensure competent
evidence is presented.
11. HOW DO I OBTAIN AND PROVIDE DOCUMENTS?
The Department of Revenue will mail to each party a
certified copy of documents from its file regarding the
case. To have other documents considered, you must
arrange delivery of the document copies to the special
deputy and each address listed on the hearing notice
prior to the scheduled date of the hearing. Documents
which are not available to all parties or their
representatives at the hearing will not be considered
by the special deputy, absent waiver. The special
deputy will consider documents in the case file and those
received before or at the hearing. Most documents and
affidavits are hearsay and may be used for the purpose of
supplementing or explaining other evidence or to support
a finding if it would be admissible over an objection in
civil actions. An employer who must rely on business
records should provide a witness who can testify how the
records were prepared and vouch for their authenticity.
Once the hearing is closed, no additional evidence
will be accepted.
12. DO I NEED AN ATTORNEY?
Professional representation at the hearing is not required.
You do, of course, have the right to be accompanied,
represented, or advised by an attorney or authorized
representative at your own expense. Any fees for
representing a claimant who is joined as a party must be
approved by the special deputy; however, the fee must be
paid by the claimant.
13. WHAT IF I NEED A TRANSLATOR?
The hearing will be conducted in English. When
necessary, the Petitioner and Respondent must provide
their own translators. Translators will be provided for
claimants who are joined as parties and indicate a
primary language other than English. If a translator is
needed by a Joined Party and the Notice of Telephone
Hearing does not advise that translation is arranged,
have the special deputy clerk contacted at once to advise
what language is needed so arrangements for translation
can be made. The special deputy clerk’s telephone
number is on the Notice of Telephone Hearing.
14. WHO SHOULD I CONTACT FOR INFORMATION?
The address of the Appeals Office is shown on the
Notice of Telephone Hearing, as well as the name,
telephone number and fax number of the special deputy
clerk who should be contacted to provide or receive
information. Include the docket number and employer
account number on all correspondence.
15. WHAT ARE THE HEARING PROCEDURES?
The special deputy assigned to the case will:
A. Explain the issues, purpose of the hearing, order of
testimony, and other procedures;
B. Identify the documents received from the parties;
C. Place all witnesses under oath or affirmation;
D. Question parties and witnesses to obtain facts;
E. Determine whether testimony and documents being
offered should be received and considered;
F. Rule on motions entered by the parties;
G. Electronically record the hearing;
H. Take official notice of well-established matters of
DEO Form UCA Bulletin 6SD (Rev. 4/12)
common knowledge and public record;
I. Record the entire hearing.
20. WHAT IS THE DIFFERENCE BETWEEN INDEPENDENT
16. WHAT HAPPENS AFTER THE HEARING?
*The parties may within 15 days after the close of the
hearing submit written proposed findings of fact and
conclusions of law. However, no additional evidence
will be accepted after the hearing has been closed.
When the time for filing proposed findings and
conclusions expires, the special deputy will prepare and
transmit a Recommended Order to the Director,
including the special deputy’s proposed findings of fact
and conclusions of law together with the record of the
proceedings and the parties’ proposed findings and
conclusions.
A party aggrieved by the Recommended Order may
file written Exceptions to the Director within fifteen (15)
days of the Recommended Order mailing date.
An opposing party may file Counter Exceptions
within ten (10) days of the mailing of Exceptions.
A Brief in Opposition to the Counter Exceptions
may be filed within ten (10) days of the mailing of the
Counter Exceptions.
*You must send a copy of any correspondence listed in
this section to each address on the Notice of Telephone
Hearing and indicate that the copies were sent.
17. CAN THE TIME LIMIT BE EXTENDED?
An extension of time can be granted for submitting
proposed Findings of Fact and Conclusions of Law,
Exceptions, Counter Exceptions, and/or Briefs if an
application for extension of time, including the reason
for the request and the amount of time requested, is
received by the special deputy, in writing, before the
expiration of the original deadline.
In Cantor v. Cochran, 184 So.2d 173 (Fla. 1966), the
Supreme Court of Florida adopted the tests in 1
Restatement of Law, Agency 2d Section 220 (1958) to
determine whether an employer-employee relationship
exists. Among the factors to be considered are:
(1) A servant is a person employed to perform services
for another and who, in the performance of the
services, is subject to the other's control or right of
control.
(2) The following matters of fact, among others, are to
be considered:
(a) the extent of control which, under the agreement,
the business may exercise over the details of the
work;
(b) whether the worker is in a distinct occupation or
business;
(c) whether the type of work is usually done under
the direction of the employer or by a specialist
without supervision;
(d) the skill required;
(e) who supplies the place of work, tools, and
materials;
(f) the length of time employed;
(g) the method of payment;
(h) whether the work is part of the regular business of
the employer;
(i) whether the parties believe the relationship is
independent;
(j) whether the principal is in business.
18. WHO MAKES THE FINAL DECISION?
The Director of the Department of Economic
Opportunityor the Director’s designee will issue a Final
Order and serve a copy to the parties by certified mail.
19. WHAT IF I DISAGREE WITH THE ORDER?
Orders of the Director become final when the time
expires for seeking judicial review, provided such review
has not been invoked. Final Orders may be appealed to
the appropriate District Court of Appeal.
CONTRACTORS AND EMPLOYEEES
21. WHERE CAN I FIND MORE INFORMATION?
Information regarding special deputy hearings,
Reemployment Assistance tax, claims, and appeals can
be found on the Internet at www.floridajobs.org.
In accordance with the Americans with Disabilities Act,
persons needing special accommodation to participate in
the hearing may contact the deputy clerk at the number
shown on the Notice of Telephone Hearing at least 5 days
before the hearing or via Florida Relay Service at 1-800955-8770.
The Florida Department of Economic Opportunityis an equal
opportunity agency, offering all persons the benefits of
participating in each of its programs and competing in all
areas of employment regardless of race, color, religion, sex,
national origin, age, handicap, or other non-merit factors.
Important Reminders
Telephone Number: Prior to the hearing, you must
provide your telephone number to the special deputy
clerk or the name and telephone number of your contact
person to be telephoned for the hearing. Failure to do so
may result in an adverse decision. Claimants who are
joined as parties may call the special deputy clerk collect
to provide telephone number information.
Witnesses: To have a witness testify by telephone,
advise the witness to be present at your location. (See
Sections 5 and 6 for more information.
Department of Revenue File: If you do not receive a
copy of the case file from the Department of Revenue at
least five days before the hearing, contact the special
deputy clerk to arrange mailing of a second copy.
Documents: If you wish to have documents entered in
evidence, arrange for delivery of the document copies to
the special deputy and all parties listed on the hearing
notice prior to the scheduled date of the hearing.
Documents which are not available to all parties or
their representatives at the hearing will not be
considered by the special deputy, absent waiver.
Permission to Record: To record the hearing yourself,
you must obtain permission to record from all hearing
participants.
Telephone Equipment: An extension or speaker
telephone will be necessary if more than one person will
participate in the telephone hearing from the same
telephone number. A party without appropriate telephone
access should immediately telephone the special deputy
clerk to make suitable arrangements. Failure to do so
may delay the hearing.
THE APPEALS OFFICE IS SHOWN ON THE
NOTICE OF TELEPHONE HEARING
This pamphlet is for informational purposes only and
does not have the full effect of law and/or regulations.
This pamphlet explains the special deputy hearing
process and how to prepare for your hearing. If you still
have questions after reading this pamphlet, contact the
deputy clerk whose telephone number appears on the
Notice of Telephone Hearing or check the DEO website:
http://www.floridajobs.org/job-seekers-communityservices/unemployment-compensation-benefits-center/file-anappeal/special-deputy-appeals-hearing-information
Special deputies conduct hearings and issue
Recommended Orders on tax rate, reimbursement, and
liability protests. Hearings are held in accordance with
the provisions of Chapters 120 and 443, Florida Statutes,
and Rule 73B-10, Florida Administrative Code. A Notice
of Telephone Hearing is mailed to all parties at least
fourteen (14) days before the scheduled hearing date and
includes, among other things, the name of the special
deputy, the name and telephone number of the special
deputy clerk, the date and time of the telephone hearing,
the location if an in-person hearing is scheduled, and the
issue(s) before the special deputy.
Before the hearing, provide to the special deputy clerk
your name and telephone number or the name and
telephone number of the person who will represent you
at the hearing. Be available to receive the telephone call
at least ten minutes before the scheduled hearing time.
Contact the deputy clerk at the number on the Notice
of Telephone Hearing if you do not receive a
telephone call within ten minutes after the scheduled
hearing time.
DEO Form UCA Bulletin 6SD (Rev. 4/12)
STATE OF FLORIDA
D.U.A. CLAIMS
PO DRAWER 5350
TO_______________________________
__________________________________
__________________________________
__________________________________
DATE_____________________________
Claimant ___________________________
S.S. Acct. No. ______________________
The above claimant has filed a Disaster Unemployment Assistance Claim (DUA) in Florida
under FEMA # _________________. The claimant has stated that work was performed in
your state during the period of ___________________________ through ________________.
Although these wages are not in the base period, may not be covered employment, and you
are not requested to transfer such wages, they are needed in the computation of the DUA
Weekly Assistance Amount. No charges will be levied against your state in connection with
this DUA claim.
Your cooperation and prompt reply will be greatly appreciated as no DUA weekly assistance
allowance can be paid to this claimant until this information is received.
Claimant listed the following employment:
Please provide the following information
and return to the address above.
Employer Name:
Dates worked
From ___________________ Thru ___________________
Payroll Address:
Number of weeks worked ____________________________
Where Work Performed:
Gross wages paid $_________________________________
Type of Work:
From
Dates Worked
Thru
Employer Name:
Dates worked:
From ____________________ Thru __________________
Payroll Address:
Where Work Performed:
Number of weeks worked_________________________
Type of Work:
From
Employer Name:
Dates Worked
Thru
Gross wages paid $ _________________________________
Replying Department Comments:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Replying Department Representative
(Signed) __________________________
Title_____________________________
Date____________________________
UCB-DUA-4 (Rev 9/11) 3102
Item 23
AFFIDAVIT FOR DUPLICATE WARRANT
Section 17.13, Florida Statutes, as amended
STATE OF FLORIDA
County:
SS#:
Before the undersigned, an Officer Duly Authorized to Take Acknowledgement, personally appeared the payee or
responsible State Agency representative:
CLAIMANT NAME:
who, being duly sworn, deposes and says that CLAIMANT is informed and believes that the State of Florida did issue a
warrant as described below:
Warrant
Date:
Warrant No.:
SAMAS
Account Code:
Warrant
Amt.:
75-71-2-765002-75200200-00-110231-00
Payable to the
Order of:
__________________________________________________________________________________
and CLAIMANT further says that according to CLAIMANT’s best knowledge, information and belief, the said warrant has
been lost or destroyed and the PAYEE has not benefited in any way directly or indirectly from the above indicated
warrant.
Has PAYEE endorsed the above warrant?
YES
NO
If the answer is yes, describe the circumstances:
Claimant
Signature:
Title (if other
than individual:
Address:
City,
State, Zip
There must be two witnesses for payees who cannot sign their names. The Notary can be one witness.
WITNESS:
WITNESS:
ADDRESS:
ADDRESS:
CTY ST ZIP1:
CTY ST ZIP2:
Sworn to and subscribed before me this ______ day of _________________, _______ by:
(Name of person making statement)
(Signature of Notary Public) State of Florida
(Print, type or stamp Commissioned name of Notary Public)
Personally Known
The State of Florida requires a notary public seal shall be affixed to all
notarized documents. This seal shall include “Notary Public-State of
Florida” (or State you are notarized in). This seal shall also state name of
notary public, commission expiration date and a commission number. If
your State does not require a commission number, then a letter with a
copy of your State’s Notary Public laws must be attached to the affidavit
for duplicate in order for the State of Florida to accept that affidavit and
process that duplicate.
or Produced Identification
Type of Identification Produced
Identification Number
This form should be completed by the payee and forwarded to the agency which initiated the payment.
RETURN WARRANT TO:
FOR STATE AGENCY USE ONLY
AGENCY SHOULD FORWARD THIS FORM TO:
Department of Economic Opportunity
Special Payments
PO Drawer 5350
Department of Financial Services
Reconciliation Section
200 E. Gaines Street
Information you provide to this department is voluntary and confidential but is required to process your claim. Pursuant to the Internal Revenue Code of 1986, the
Social Security Act, 42 U.S.C. 1320b-7(a)1, and s. 443.091(1)(h), F.S., disclosure of your Social Security number is mandatory. Social Security numbers will be used by
the department to report the benefits you receive to the Internal Revenue Service as potential taxable income. In accordance with the Federal Deficit Reduction Act,
an amendment to the Federal Social Security Act, and 5 U.S.C. 552a(o)(1)(D), information you provide is subject to verification through computer matching programs
and information about your wages and claim may be provided to other federal, state and local agencies or their contractors for verification of eligibility under other
government programs to ensure benefits have been properly paid and for statistical and research purposes.
Form DFS-A1-408
UCB-15 (Rev. 9/11)
AFFIDAVIT FOR DUPLICATE WARRANT
Section 17.13, Florida Statutes, as amended
INFORMATION SHEET FOR AFFIDAVIT FOR DUPLICATE WARRANT
You must have your signature notarized on the Affidavit for Duplicate Warrant, fill in your current mailing
address in the space provided, and return the notarized affidavit to the address below. We will not place a
STOP PAYMENT on this warrant until we receive the completed, notarized ORIGINAL affidavit from
you.
SPECIAL PAYMENTS
PO DRAWER 5350
If you receive or locate the original warrant after submitting this affidavit, DO NOT CASH the
warrant, as payment will be stopped by the State Treasurer. The original warrant must be sent back
to the above address with a note advising that a stop payment was requested on the warrant.
If it is determined by the Department of Financial Services that the original warrant has not been
cashed, a replacement warrant marked DUPLICATE will be issued to you within two weeks following
receipt by this mailed to your current mailing address you provided on the Affidavit for Duplicate Warrant.
If it is determined that the original warrant was cashed prior to issuance of the stop payment order, you
will be notified and given further instructions.
Form DFS-A1-408
UCB-15 (Rev. 9/11)
316
P.O. DRAWER 5300
Nimewo Telefòn 1-866-778-7356 Nimewo Faks 850-921-3919
DAT LI POSTE ______________________
Benefis Asistans pou edew Retounen Travay Nan Lòt Eta
Keksyonè pou Revizyon Elijibilite
Revizyon elijibilite a fèt yon mannyè peryodik pandan alokasyon ou an pou verifye elijibilite kontinyèl ou pou
prestasyon asistans pou edew retounen travay. Tanpri ranpli toude bò fòm sa a epi voye fòm ranpli a tounen disi
14 jou nan adrès ki endike pi wo a. Si ou pa fè sa, sa gen dwa lakòz reta oubyen refi prestasyon yo.
Adrès Imel:
NIMEWO SEKIRITE SOSYAL
NIMEWO TELEFÒN
1. Bay lis tip travay w’ap chèche yo ak kantite ane esperyans ou genyen nan chak:
2. Salè pi ba ou dispoze asepte $
pa (make yon sèl)
È
Semèn
Mwa
Ane
3. Ki jou ak lè ou dispoze travay?
4. Konbyen mil ALE SÈLMAN ou dispoze fè pou al travay?
5. Kijan ou ta pwal travay? (machin, bis, mache, elatriye)
6. Èske ou te kapab ak disponib pou travay depi ou te fè demann alokasyon ou a?
Wi
Non
Si ou reponn “Non”, tanpri esplike:
7. Èske gen ankenn rezon ki fè ou pa ka asepte yon òf travay a plentan?
Wi
Non
Si ou reponn “Wi”, poukisa:
8. Èske ou ale, oubyen ap planifye al lekòl oubyen nan yon pwogram fòmasyon ?
Kòmanse ki lè?
/
/
Tip Fòmasyon:
Wi
Non
Ki Kote?
Jou ak lè w’al lekòl oubyen nan fòmasyon:
9. Èske ou kòmanse resevwa pansyon nan men yon ansyen anplwayè depi ou fè demann alokasyon ou an?
Wi
Non
Si ou reponn “Wi”: konbyen pa mwa? $
10. Èske ou gen òf travay fèm?
Wi
Kòmanse ki lè?
/
/
Nan men kii anplwayè?
Non
Si ou reponn “Wi”, dat ou sipoze kòmanse a:
/
/
Non anplwayè a:_____________________
11. Èske ou fè ankenn travay, a plentan oubyen a tan pasyèl (travay endepandan ladann tou), depi demann alokasyon ou
an?
Wi
Non
Si ou reponn “Wi”, reponn bagay sila yo:
Non Anplwayè a:
Telefòn: (
)
-
Adrès Anplwayè a:
Dat ou te kòmanse travay:
/
/
Dènye dat ou te travay:
/
/
Rezon ki fè ou pa travay ankò:
Pou ba w’ asistans nan jwenn travay, nou rekòmande pou ou kontakte Sant Karyè Santralize ki pi pre lakay ou a, ki ofri anpil sèvis.
Sant Karyè Santralize a kapab bay zouti pou ede w’ nan pwosesis chèche travay ou a tankou referans pou djòb, konsèy ak anpil lòt
sèvis. Oka ou t’al nan Sant Karyè Santralize a deja, tanpri al wè yo ankò paske opòtinite travay ki disponib yo chanje souvan. Rezidan
Florida gen dwa vizite sit wèb nou an tou nan http://www.floridajobs.org. Si ou pa rete Florida, vizite bank djòb Etazini a nan
http://www.ajb.org oubyen rele 1-877-US-2JOBS.
Form UCB-230 (Rev. 02/12)
RAPÒ SOU RECHÈCH TRAVAY
Tanpri bay lis tout kontak rechèch travay ou fè yo depi lè ou te soumèt demann alokasyon ou
an oubyen depi dènye fwa ou soumèt fòm sa a. Si ou pa bay kontak rechèch travay ou yo sa
gen dwa lakòz reta oubyen refi prestasyon yo.
(Mete kontak rechèch travay ou genyen anplis yo sou yon fèy separe)
DAT
NON, ADRÈS AK NIMEWO TELEFÒN
ANPLWAYÈ A
METÒD
KONTAK
REZILTA
VERIFYE
(pou itilizasyon
Ajans la)
Enfòmasyon mwen bay pi wo yo vre ak kòrèk selon sa m’ konnen. Si mwen reyisi jwenn travay, m’ap rapòte TOUT revni
brit mwen (anvan taks) kòrèkteman nan semèn mwen resevwa yo a lè m’ap fè demann prestasyon yo. Si mwen gen
keksyon sou pwosesis benefis asistans pou edew retounen travay la, m’ap kontakte Sant Sèvis Kliyantèl la nan 1-866778-7356. Mwen konprann ke Florida Reemployment Assistance Law [Lwa Florida sou Asistans pou edew Retounen
Travay] enpoze penalite pou fo deklarasyon pou jwenn benefis.
Siyati Demandè a:
Dat:
Asistencia de Reempleo
Cuestionario de la Revisión de la Elegibilidad del Reclamante
La revisión de elegibilidad se conduce periódicamente a lo largo de su reclamación para asegurar la elegibilidad continua para recibir
beneficios de asistencia de reempleo. Por favor responda todas las preguntas en este formulario y presente una lista de todos los contactos de
trabajo hechos desde la última vez que usted llenó este formulario o registró su reclamación. Su lista de contactos de trabajo debe incluir la
fecha de su contacto, el nombre del empleador, dirección y número de teléfono, método de contacto (en-persona, por teléfono, correo, Internet,
etc.), y los resultados de sus contactos. Este formulario y su lista de los contactos de trabajo deben ser devueltos en el plazo de 10 días de la
fecha en que se enviaron por correo a la dirección al dorso de este formulario. La falla en hacerlo así puede resultar en una demora o negación
de beneficios.
FECHA DE ENVÍO POR CORREO
NOMBRE
/
-
NÚMERO DE SEGURO SOCIAL
Dirección de E-mail
/
-
-
NÚMERO DE TELÉFONO
-
1.
Liste los tipos de trabajo que usted está buscando y el número de años de experiencia que usted tiene en cada uno:
2.
Menor salario que usted está dispuesto a aceptar:
3.
¿Qué días y horas está usted dispuesto a trabajar?
4.
¿Cuántas millas EN UNA DIRECCIÓN está usted dispuesto a viajar a diario para ir a trabajar?
5.
¿Cómo se transportaría usted a trabajar? (carro, autobús, caminando, etc.)
6.
¿Ha estado usted capaz y disponible para trabajar a tiempo completo desde que registró su reclamación?
por (marque una)
$
Hora
Semana
Mes
Año
SI
NO
SI
NO
SI
NO
SI
NO
SI
NO
Si “NO”, por favor explicar:
7.
¿Hay alguna razón por la que usted no pueda aceptar una oferta de trabajo a tiempo completo?
¿Si “SI”, por qué?
8.
¿Está usted ahora asistiendo, o tiene planeado asistir a un programa de escuela o entrenamiento?
¿Comenzando cuando?
/
/
¿Qué tipo de entrenamiento?
¿Dónde?
Días y horas que usted asiste a la escuela o entrenamiento
9.
¿Ha comenzado usted a recibir una pensión de un empleador para quien usted ha trabajado desde que
registró su reclamación?
Si “SI”, ¿Cantidad mensual?
10.
$
¿Comenzando cuando?
/
SI
¿Tiene usted ofertas concretas de trabajo?
Si “SI”, fecha programada para comenzar:
11.
/
/
/
¿Cuál empleador?
NO
Nombre del empleador:
¿Ha realizado usted cualquier trabajo, a tiempo completo o medio tiempo (incluyendo empleo
independiente), desde que comenzó su reclamación?
Si “SI”, responda lo siguiente:
Nombre del Empleador:
Número de teléfono:
(
)
-
Dirección del Empleador:
Fecha en la que usted comenzó a trabajar:
/
/
Última fecha que usted trabajó:
/
/
Razón por la que ya no está empleado:
Para asistirle en adquirir empleo, se recomienda que usted haga contacto con el Centro de Carreras Directo [One Stop Career Center] más cercano de su área, el cual ofrece
muchos servicios. El Centro de Carreras Directo [One Stop Career Center] puede proporcionar herramientas para asistirle en su proceso de búsqueda de trabajo incluyendo
remisiones de trabajo, asesoramiento y muchos otros servicios. En caso que usted haya estado en un Centro de Carreras Directo [One Stop Career Center] anteriormente, por
favor hágales una visita de nuevo ya que las oportunidades de trabajo disponibles cambian con frecuencia. Los residentes de la Florida también pueden visitar nuestro Sitio Web
en http://www.floridajobs.org. Si usted reside fuera de la Florida, visite el banco de trabajos de América en http://www.ajb.org o llame al 1-877-US-2JOBS.
La información que he proporcionado arriba es verdadera y correcta a mí mejor saber. Si tengo éxito en encontrar trabajo, informaré correctamente mis ganancias brutas (antes
de los impuestos) en la semana en la cual SON GANADAS al solicitar cheques de beneficios. Si tengo cualesquiera preguntas con respecto al proceso de asistencia de
reempleo, me comunicaré con el número de teléfono de información de Reclamaciones llamando al 1-800-204-2418. Entiendo que la Ley de Asistencia de reempleo de la Florida
impone penas por hacer declaraciones falsas para obtener beneficios de asistencia de reempleo.
Firma del Reclamante:
Fecha:
DECLARACIÓN DE LA LEY DE PRIVACIDAD
La información que usted proporciona a este departamento es voluntario y confidencial pero se requiere para procesar su reclamación. Conforme al Código de Rentas Internas de 1986, la Ley de Seguro
Social, 42 U.S.C. 1320b-7(a)1, y s. 443.091(1)(h), F.S., la divulgación de su número de Seguro Social es obligatoria. Los números de Seguro Social serán utilizados por el departamento para informar sobre
los beneficios que usted recibe al Servicio de Rentas Internas como potenciales ingresos imponibles. De acuerdo con la Ley Federal de Reducción del Déficit, una enmienda a la Ley Federal del Seguro
Social, y 5 U.S.C. 552a(o)(1)(D), la información que usted proporcione está sujeta a verificación con programas de computadora utilizados para emparejar datos y la información sobre sus salarios y
reclamación se pueden proporcionar a otras agencias federales, estatales y locales o sus contratistas para la verificación de elegibilidad bajo otros programas del gobierno para asegurar que los beneficios se
han pagado correctamente y para propósitos de estadísticas e investigación.
Un programa de empleador de oportunidades iguales. Dispositivos y servicios auxiliares se encuentran disponibles a petición para individuos con discapacidades.
DEO Form UCB-231
(Rev. 02/12)
REEMPLOYMENT ASSISTANCE
CHANGE OF ADDRESS / PIN RESET AUTHORIZATION
(USE THIS FORM TO VERIFY IDENTITY FOR A REQUEST WITHOUT A SIGNATURE)
PIN RESET
CHANGE OF ADDRESS
TELEPHONE REQUEST
E-MAIL REQUEST
NAME:
SS #:
BYE:
INFORMATION VERIFIED FROM DATA ON CLAIM HISTORY:
BIRTH DATE
ADDRESS
PRIOR ADDRESS (REQUIRED FOR CHANGE OF ADDRESS)
NAME OF LAST EMPLOYER AND LAST DATE WORKED
NEW ADDRESS:
CITY:
STATE:
TELEPHONE:
E-MAIL:
RESIDENT COUNTY:
COUNTY CODE:
COST CENTER NUMBER:
STATE CODE:
PROCESSED BY:
DATE:
E-MAIL ADDRESS ENTERED IN BH31 COMMENT
DEO-UC350 (2/12)
ZIP CODE:
LOCAL OFFICE WEEKLY CLAIM CERTIFICATION
FOR OFFICE USE ONLY – DO NOT WRITE IN THIS SECTION
BP60
SSN
BYB
Issue
Claims Taker’s
Initials
Suppress
Subsequent
Program ID
IMPORTANT – CAREFULLY COMPLETE THIS FORM AS INSTRUCTED
Claimant Name:
Social Security:
MARK THE CORRECT ANSWER
EXAMPLE: IF ANSWER YES
21
1.
I claim reemployment assistance benefits for these
weeks
2.
DURING EACH WEEK:
(A) Did you look for work as instructed by this
department?
(B) Were you able and available to work, if work
had been offered to you?
(C) Did you refuse any offer of work?
(D) During each of the weeks listed, did you work
or earn any money?
IF YES:
(1) Enter date you began work .…..../.……./….…..
MONTH
(2)
(3)
(4)
(5)
(6)
DAY
IF NO
YES
NO
WEEK-ENDING
MM / DD / YY
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
No
No
Yes
Yes
No
No
$
$
YEAR
(a) Enter last date worked: ………/.….../…….
3.
4.
NO
WEEK-ENDING
MM / DD / Y Y
Enter your earnings before deductions
Name of Employer______________________________
Street Address___________________________________
City, State, Zip___________________________________
Are you still working for this employer?
(a) Are you working full-time?
(7) If you are no longer working for this employer
MONTH
YES
-
DAY
Yes
Yes
No
No
Lack Of Work
Yes
Yes
Discharge
No
No
Quit
YEAR
If mailing address has changed since your last certification mark here and enter your new address on the reverse side.
CERTIFICATION: I certify that all the above statements and answers are true and correct. I am unemployed or partially
employed, I am not receiving reemployment assistance benefits from another state, and I am aware I may be prosecuted in
a court of law for giving false statements or answers or for withholding information.
Claimant Signature_________________________________
DEO Form UCB-61 Rev (2/12)
Phone No. (
)
-
________

information on filing a claim to receive reemployment assistance

Transcripción

Documentos relacionados

May 1, 2016 - St. Augustine

August 21, 2016 Sacred Heart Catholic Church

St. Augus ne Roman Catholic Church

Give Me 5 Fund Raiser Middle School Valentines Dance Senior