Form DWS-ARK-AT-213 "Petition for Appeal to Appeal Tribunal" - Arkansas

What Is Form DWS-ARK-AT-213?

This is a legal form that was released by the Arkansas Department of Workforce Services - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 23, 2019;
  • The latest edition provided by the Arkansas Department of Workforce Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DWS-ARK-AT-213 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Workforce Services.

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Download Form DWS-ARK-AT-213 "Petition for Appeal to Appeal Tribunal" - Arkansas

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PETITION FOR APPEAL
ARKANSAS APPEAL TRIBUNAL
Post Office Box 8013
TO APPEAL TRIBUNAL
Little Rock, AR 72203
ALL ENTRIES ON THIS FORM EXCEPT SIGNATURES SHOULD BE PRINTED OR TYPED
1. CLAIMANT'S FIRST NAME:
CLAIMANT'S LAST NAME:
2. SOCIAL SECURITY NUMBER:
BENEFIT YEAR:
3. ADDRESS: (STREET OR BOX NUMBER):
(CITY):
(STATE):
(ZIP CODE):
5. ISSUE(S) APPEALED:
4. TELEPHONE NUMBER:
Section(s):
6. I / We appeal from the determination of the Division of Workforce Services for the following reason(s)
(Please attach a copy of the determination):
7. APPELLANT SIGNATURE:
8. APPELLANT (CHECK ONE):
Claimant
Employer
NOTE TO CLAIMANT FROM DWS: To protect your potential rights to benefits, you must continue filing a claim each week,
making your work search as instructed, and reporting to your local office as directed during the time your appeal is pending
unless you are working full-time.
QUESTIONS BELOW ARE FOR LOCAL OFFICE USE ONLY
Yes
No
9. Agency Representative To Testify? (CHECK ONE)
If Yes,
(Name)
(Title)
Phone Number:
10. TYPE OF CLAIM:
UI
UCFE
UCX
EB
TRA
OTHER
11. APPEAL FILED:
(A) In person on
(Date)
(B) By mail
(Postmark Date) (Attach Envelope)
12. EMPLOYER PHONE NUMBER:
13. EMPLOYER ADDRESS CONFIRMATION (CHECK ONE):
Yes
No
A. Are employer name and address on the Determination complete and correct?
If no, enter the complete name and mailing address in the space indicated below.
14. APPEAL RECEIVED BY: (INTERVIEWER):
Yes
No
B. Are employer name and address omitted from the Determination?
If yes, enter the complete name and mailing address in the space indicated below
15. LOCAL OFFICE ADDRESS:
16. EMPLOYER ADDRESS CORRECTION:
ADDRESS:
NAME OF EMPLOYER:
CITY:
STATE:
ZIP CODE:
ADDRESS:
CITY:
STATE: ZIP CODE:
PHONE NUMBER:
DWS-ARK-AT-213 v08232019
Page of
PETITION FOR APPEAL
ARKANSAS APPEAL TRIBUNAL
Post Office Box 8013
TO APPEAL TRIBUNAL
Little Rock, AR 72203
ALL ENTRIES ON THIS FORM EXCEPT SIGNATURES SHOULD BE PRINTED OR TYPED
1. CLAIMANT'S FIRST NAME:
CLAIMANT'S LAST NAME:
2. SOCIAL SECURITY NUMBER:
BENEFIT YEAR:
3. ADDRESS: (STREET OR BOX NUMBER):
(CITY):
(STATE):
(ZIP CODE):
5. ISSUE(S) APPEALED:
4. TELEPHONE NUMBER:
Section(s):
6. I / We appeal from the determination of the Division of Workforce Services for the following reason(s)
(Please attach a copy of the determination):
7. APPELLANT SIGNATURE:
8. APPELLANT (CHECK ONE):
Claimant
Employer
NOTE TO CLAIMANT FROM DWS: To protect your potential rights to benefits, you must continue filing a claim each week,
making your work search as instructed, and reporting to your local office as directed during the time your appeal is pending
unless you are working full-time.
QUESTIONS BELOW ARE FOR LOCAL OFFICE USE ONLY
Yes
No
9. Agency Representative To Testify? (CHECK ONE)
If Yes,
(Name)
(Title)
Phone Number:
10. TYPE OF CLAIM:
UI
UCFE
UCX
EB
TRA
OTHER
11. APPEAL FILED:
(A) In person on
(Date)
(B) By mail
(Postmark Date) (Attach Envelope)
12. EMPLOYER PHONE NUMBER:
13. EMPLOYER ADDRESS CONFIRMATION (CHECK ONE):
Yes
No
A. Are employer name and address on the Determination complete and correct?
If no, enter the complete name and mailing address in the space indicated below.
14. APPEAL RECEIVED BY: (INTERVIEWER):
Yes
No
B. Are employer name and address omitted from the Determination?
If yes, enter the complete name and mailing address in the space indicated below
15. LOCAL OFFICE ADDRESS:
16. EMPLOYER ADDRESS CORRECTION:
ADDRESS:
NAME OF EMPLOYER:
CITY:
STATE:
ZIP CODE:
ADDRESS:
CITY:
STATE: ZIP CODE:
PHONE NUMBER:
DWS-ARK-AT-213 v08232019
Page of

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