Form UB-126-FF "Request for Reconsideration/Appeal" - Arizona

What Is Form UB-126-FF?

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

Form Details:

  • Released on March 1, 2018;
  • The latest edition provided by the Arizona Department of Economic Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form UB-126-FF by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

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Download Form UB-126-FF "Request for Reconsideration/Appeal" - Arizona

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UB-126-FF (3-18)
REQUEST FOR RECONSIDERATION/APPEAL
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Unemployment Insurance Program
P.O. Box 29225, Mail Drop 5895, Phoenix, AZ 85038
Fax (602) 364-1210 or (520) 770-3357
In the matter of the claim of:
CLAIMANT’S NAME (Last, First, M.I.)
Address
SOC. SEC. NO.
EMPLOYER’S NAME
Este documento afecta su elegibilidad para seguro por desempleo. Si usted no lee inglés, comuníquese con la oficina de
acceso rápido de reemplo de Arizona (ARRA) al 602-364-2722 (Condado de Maricopa) 520-791-2722 (Condado de Pima
o 877-600-2722 (los demás áreas).
I disagree with the Determination of Deputy dated
involving the issue of:
and allege it is in error for the following reasons:
I also disagree with the determination of Overpayment dated
created by the above Determination
of Deputy.
If request is not timely, state reason:
APPELLANT’S SIGNATURE
DATE
NOTICE TO CLAIMANT
If your Request for Reconsideration is denied, and you are still unemployed and wish to claim benefits, you
should continue to file claims pending disposition of your appeal.
COMPLETED BY DEPARTMENT REPRESENTATIVE
REQUEST FILED:
In person on
By mail postmarked on
(envelope attached)
Date
Date
Received at
on
Claimant requests an interpreter
Yes
No
Information not available
Language
NOTICE TO APPELLANT REGARDING RECONSIDERATION
Your request has been reviewed and a reconsidered Determination of Deputy will be issued.
Your request for reconsideration has been denied on
and this action will be forwarded to the
Date
Office of Appeals. The specific date and location for your appeal hearing will be provided in a separate communication.
The hearing will be conducted in English (unless you request an interpreter)
BY (Department Representative)
APPROVED (UI Manager)
PAU-174 RESOLUTION CODE
ISSUE ID
PROGRAM CODE
See reverse for EOE/ADA/LEP/GINA disclosure
UB-126-FF (3-18)
REQUEST FOR RECONSIDERATION/APPEAL
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Unemployment Insurance Program
P.O. Box 29225, Mail Drop 5895, Phoenix, AZ 85038
Fax (602) 364-1210 or (520) 770-3357
In the matter of the claim of:
CLAIMANT’S NAME (Last, First, M.I.)
Address
SOC. SEC. NO.
EMPLOYER’S NAME
Este documento afecta su elegibilidad para seguro por desempleo. Si usted no lee inglés, comuníquese con la oficina de
acceso rápido de reemplo de Arizona (ARRA) al 602-364-2722 (Condado de Maricopa) 520-791-2722 (Condado de Pima
o 877-600-2722 (los demás áreas).
I disagree with the Determination of Deputy dated
involving the issue of:
and allege it is in error for the following reasons:
I also disagree with the determination of Overpayment dated
created by the above Determination
of Deputy.
If request is not timely, state reason:
APPELLANT’S SIGNATURE
DATE
NOTICE TO CLAIMANT
If your Request for Reconsideration is denied, and you are still unemployed and wish to claim benefits, you
should continue to file claims pending disposition of your appeal.
COMPLETED BY DEPARTMENT REPRESENTATIVE
REQUEST FILED:
In person on
By mail postmarked on
(envelope attached)
Date
Date
Received at
on
Claimant requests an interpreter
Yes
No
Information not available
Language
NOTICE TO APPELLANT REGARDING RECONSIDERATION
Your request has been reviewed and a reconsidered Determination of Deputy will be issued.
Your request for reconsideration has been denied on
and this action will be forwarded to the
Date
Office of Appeals. The specific date and location for your appeal hearing will be provided in a separate communication.
The hearing will be conducted in English (unless you request an interpreter)
BY (Department Representative)
APPROVED (UI Manager)
PAU-174 RESOLUTION CODE
ISSUE ID
PROGRAM CODE
See reverse for EOE/ADA/LEP/GINA disclosure
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in
admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability,
genetics and retaliation. To request this document in alternative format or for further information about this policy, contact
your local office manager; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
Ayuda gratuita con traducciones relacionadas con los servicios del DES esta disponible a solicitud del cliente.
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