"Claimant Request for Hearing" - New York

Claimant Request for Hearing is a legal document that was released by the New York State Department of Labor - a government authority operating within New York.

Form Details:

  • Released on March 1, 2018;
  • The latest edition currently provided by the New York State Department of Labor;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the New York State Department of Labor.

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Download "Claimant Request for Hearing" - New York

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Unemployment Insurance Division
PO Box 15131, Albany, NY 12212-5131
Claimant Request for Hearing
Enter the last four digits of your Social Security Number (SSN): _____ _____ _____ _____
Your Name (print):
You can request an Unemployment Insurance (UI) hearing two ways, online or by mail.
To request a hearing online, sign in to your NY.Gov account. Click on the envelope icon at the upper right of your
My Online Services page. Then create a new email message. Choose “Hearings and Appeals” from the drop-
down menu as the first subject line and “I want to request a hearing” as the second subject line.
To request a hearing by mail, complete and sign this form. Mail it to the address at the top of this form. Write
only in the space provided on this form. Do not write outside the margins or on the back. If you need more
space, use an 8 ½ x 11-inch piece of white paper. Be sure to write your name and the last four digits of your
Social Security number on all of the papers you send. Do not staple.
IMPORTANT: To protect your rights to UI benefits you may be entitled to receive, please continue to certify for UI
benefits every week, as long as you are unemployed.
I disagree with the Notice of Determination(s) dated ____/____/_______ (month, day, year), and I am requesting a
hearing. Reason (optional):
If you are requesting a hearing on a determination that was made more than 30 days ago, please state the reason for the
delay in notifying us:
Last Employer’s Name:
Physical work location (place where you regularly reported to work):
Street
City
State
Zip Code
Work Phone Number: (
)
Would you like your hearing conducted in a language other than English?
Yes
No
If yes, what language and dialect?
Dates you are unavailable for a hearing:
Email:
Phone: (
)
Mailing Address:
Apt/Floor:
City:
State:
Zip:
Signature
Date
For information about the UI Claimant Advocate Office and to view a video on how to prepare for a hearing, visit our
website at
https://www.labor.ny.gov/ui/claimantinfo/claimant-advocate.shtm
LO 435 (03/18)
Unemployment Insurance Division
PO Box 15131, Albany, NY 12212-5131
Claimant Request for Hearing
Enter the last four digits of your Social Security Number (SSN): _____ _____ _____ _____
Your Name (print):
You can request an Unemployment Insurance (UI) hearing two ways, online or by mail.
To request a hearing online, sign in to your NY.Gov account. Click on the envelope icon at the upper right of your
My Online Services page. Then create a new email message. Choose “Hearings and Appeals” from the drop-
down menu as the first subject line and “I want to request a hearing” as the second subject line.
To request a hearing by mail, complete and sign this form. Mail it to the address at the top of this form. Write
only in the space provided on this form. Do not write outside the margins or on the back. If you need more
space, use an 8 ½ x 11-inch piece of white paper. Be sure to write your name and the last four digits of your
Social Security number on all of the papers you send. Do not staple.
IMPORTANT: To protect your rights to UI benefits you may be entitled to receive, please continue to certify for UI
benefits every week, as long as you are unemployed.
I disagree with the Notice of Determination(s) dated ____/____/_______ (month, day, year), and I am requesting a
hearing. Reason (optional):
If you are requesting a hearing on a determination that was made more than 30 days ago, please state the reason for the
delay in notifying us:
Last Employer’s Name:
Physical work location (place where you regularly reported to work):
Street
City
State
Zip Code
Work Phone Number: (
)
Would you like your hearing conducted in a language other than English?
Yes
No
If yes, what language and dialect?
Dates you are unavailable for a hearing:
Email:
Phone: (
)
Mailing Address:
Apt/Floor:
City:
State:
Zip:
Signature
Date
For information about the UI Claimant Advocate Office and to view a video on how to prepare for a hearing, visit our
website at
https://www.labor.ny.gov/ui/claimantinfo/claimant-advocate.shtm
LO 435 (03/18)