Form B-491 "Overpayment Waiver Request" - Colorado

What Is Form B-491?

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

Form Details:

  • Released on October 1, 2018;
  • The latest edition provided by the Colorado Department of Labor and Employment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form B-491 by clicking the link below or browse more documents and templates provided by the Colorado Department of Labor and Employment.

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Download Form B-491 "Overpayment Waiver Request" - Colorado

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Colorado Department of Labor and Employment,
Division of Unemployment Insurance, Benefit Payment Control
P.O. Box 8789, Denver, CO 80201-8789
303-318-9035 (Denver-metro area) 1-877-464-4622 (outside Denver-metro area)
Fax 303-318-9037
Social Security Number
XXX-XX-
Date Mailed
In Response To Your Inquiry Dated
Overpayment Balance
WAIVER REQUEST
You were overpaid unemployment insurance (UI) benefits. You are required to repay the Division of UI the amount shown in
the Overpayment Balance above.
Attention: Fraud Overpayments that do not qualify for waiver request consideration will not be processed.
If you are unable to repay the Overpayment Balance because of financial hardship, you may request that the Division of
Unemployment Insurance stop collection efforts and waive the balance.
To request a waiver, you must submit and complete sections, II, III, and IV on the reverse side of this form. All questions
must have a response. If something does not apply to you, write N/A for not applicable.
Be sure to sign and date your waiver request. Make a copy of both sides of the completed waiver and keep it for your records
in case you need it later. Mail or fax the completed waiver using the information at the top of this form.
If you previously requested a waiver for this overpayment and were denied, that decision is final. A subsequent request for a
waiver may be submitted only if a significant change in financial conditions, such as catastrophic illness or loss of employment,
affects your ability to repay the Overpayment Balance. To report a significant change in financial conditions, complete the
reverse side of this form making sure to state clearly that you are requesting a reconsideration of a previous waiver decision
due to a significant change in your financial circumstances.
If the overpayment was caused by a decision that disqualified or disallowed you from receiving benefits, you may file an appeal
on that decision if you disagree with it. This request is not an appeal of that decision.
If you have received notice that your overpayment has been withdrawn or waived, please disregard this notice.
IMPORTANT! This document(s) contains important information about your unemployment compensation rights, responsibilities and/or benefits. It is critical
that you understand the information in this document. If needed, call 303-318-9035 for assistance in the translation and understanding of the information in
the document(s) you have received.
¡IMPORTANTE! Este documento(s) contiene información importante sobre sus derechos, obligaciones y/o beneficios de compensación por desempleo. Es
muy importante que usted entienda la información contenida en este documento. Si necesita asistencia para traducir y entender la información contenida en
el documento(s) que recibió, llame al 303-318-9035.
If you have questions regarding the completion of this form, contact Benefit Payment Control at one of the telephone
numbers above.
B-491 (R 10/2018)
Colorado Department of Labor and Employment,
Division of Unemployment Insurance, Benefit Payment Control
P.O. Box 8789, Denver, CO 80201-8789
303-318-9035 (Denver-metro area) 1-877-464-4622 (outside Denver-metro area)
Fax 303-318-9037
Social Security Number
XXX-XX-
Date Mailed
In Response To Your Inquiry Dated
Overpayment Balance
WAIVER REQUEST
You were overpaid unemployment insurance (UI) benefits. You are required to repay the Division of UI the amount shown in
the Overpayment Balance above.
Attention: Fraud Overpayments that do not qualify for waiver request consideration will not be processed.
If you are unable to repay the Overpayment Balance because of financial hardship, you may request that the Division of
Unemployment Insurance stop collection efforts and waive the balance.
To request a waiver, you must submit and complete sections, II, III, and IV on the reverse side of this form. All questions
must have a response. If something does not apply to you, write N/A for not applicable.
Be sure to sign and date your waiver request. Make a copy of both sides of the completed waiver and keep it for your records
in case you need it later. Mail or fax the completed waiver using the information at the top of this form.
If you previously requested a waiver for this overpayment and were denied, that decision is final. A subsequent request for a
waiver may be submitted only if a significant change in financial conditions, such as catastrophic illness or loss of employment,
affects your ability to repay the Overpayment Balance. To report a significant change in financial conditions, complete the
reverse side of this form making sure to state clearly that you are requesting a reconsideration of a previous waiver decision
due to a significant change in your financial circumstances.
If the overpayment was caused by a decision that disqualified or disallowed you from receiving benefits, you may file an appeal
on that decision if you disagree with it. This request is not an appeal of that decision.
If you have received notice that your overpayment has been withdrawn or waived, please disregard this notice.
IMPORTANT! This document(s) contains important information about your unemployment compensation rights, responsibilities and/or benefits. It is critical
that you understand the information in this document. If needed, call 303-318-9035 for assistance in the translation and understanding of the information in
the document(s) you have received.
¡IMPORTANTE! Este documento(s) contiene información importante sobre sus derechos, obligaciones y/o beneficios de compensación por desempleo. Es
muy importante que usted entienda la información contenida en este documento. Si necesita asistencia para traducir y entender la información contenida en
el documento(s) que recibió, llame al 303-318-9035.
If you have questions regarding the completion of this form, contact Benefit Payment Control at one of the telephone
numbers above.
B-491 (R 10/2018)
Claimant Name
Social Security Number
I. Request for an Explanation of the Overpayment. Use this section to tell us what you want explained regarding the overpayment. Give details, and
attach additional sheets of paper if needed. Please do not use this section to disagree with the reason for the overpayment. This is not an appeal form but
a request for explanation. (You may appeal the previously mailed Notice of Decision on the reverse side of that form.)
Extra sheets attached. Write your social security number on each sheet.
Request for a Waiver or Collection Suspension
Complete Sections, II, III, and IV to request a waiver. We must review your current financial situation to decide whether a waiver is granted. If we cannot
approve the waiver, you will receive a letter with an explanation of why the waiver was not granted.
II. Waiver Request. Explain in detail why you are requesting a waiver. Attach extra sheets if needed. Do not use this section to disagree with the
reason for the overpayment.
Request a reconsideration of a previous waiver decision due to a significant change in your financial circumstances.
Extra sheets attached. Write your social security number on each sheet.
III. Your Financial Situation. Tell us about your current situation.
1.
Are you currently filing for unemployment insurance benefits? Yes
No
2.
Did you file for bankruptcy? Yes
No
(If yes, attach a copy of your paperwork and complete the information below.)
Bankruptcy Number
Date Filed
3.
Did you make a new financial agreement because you are receiving unemployment benefits? Yes
No
(If yes, explain)
4.
Did any agency refuse to help you because you are getting unemployment insurance benefits? Yes
No
(If yes, explain)
5.
Are you disabled? Yes
No
(if yes, attach copies of your paperwork.)
IV. Your Financial Statement. Complete the financial statement below. If this statement is incomplete, your waiver request will not be considered.
Write N/A for anything that does not apply to you.
Income And Assets
Monthly Expenses
1.
The number of people in your household?
10.
Food and clothing
$
2.
If you are not working, for how long?
11
Utilities (gas, electric, water, telephone, etc.)
$
12.
Additional Medical/dental (expenses not already
3a. If you are working, for how long?
deducted from your pay check)
$
3b. Monthly gross wages (before deductions)
$
13.
Child care
$
3c. Monthly take-home pay (after deductions)
$
14.
Transportation (bus, fuel, etc.)
$
4a. If married, spouse’s social security number.
15.
Mortgage
$
4b. Spouse's monthly take-home pay.
16.
Second mortgage
$
Other people in your household’s monthly take-home
5.
pay.
$
17.
Rent
$
6.
Other income (social security, pension, etc.)
$
18.
Car payment
$
7.
Bank accounts, and stocks, bonds
$
19.
Second car payment
$
8a. Welfare and food stamps
$
20.
Court-ordered support you pay
$
8b. Date filed for assistance (welfare, etc.)
$
21.
Credit cards (total for all each month)
$
9.
Court-ordered child support that you receive (attach
copies of verifying documents)
22.
Insurance (total for home, car, life, etc.)
$
23.
List other
$
Total Income and Assets (Attach copies of paperwork)
$
Total Expenses
$
The information provided is true, correct, and complete to the best of my knowledge. I understand there are severe penalties, up to and including
criminal prosecution, for providing misleading or false statements.
Your Signature
Telephone Number (Include area code)
Date Signed
B-491 Reverse (R 10//2018)
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