Form 60-0169 "Unemployment Insurance Appeal Form" - Iowa

What Is Form 60-0169?

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

Form Details:

  • Released on February 1, 2016;
  • The latest edition provided by the Iowa Workforce Development;
  • 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 60-0169 by clicking the link below or browse more documents and templates provided by the Iowa Workforce Development.

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Download Form 60-0169 "Unemployment Insurance Appeal Form" - Iowa

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F O R A G E N C Y U S E O N L Y
Unemployment Insurance Appeal Form
Date received (if no postmarked envelope):
F
6 0 - 0 1 6 9 ( 0 2 - 1 6 ) 3 0 9 0 6 0 4
O R M
Claimstaker:
Attention: Unemployment Insurance Appeals Bureau and Employment Appeal Board proceedings are open to the public. This means
that the public and media have access to the hearings, exhibits, transcripts, recordings, and decisions without prior notice to you.
Unemployment Insurance Appeals Bureau decisions are posted online.
Provide the following claim information.
1) Claimant:
3) Other interested party (if applicable):
4) Decision date: ___ ___ / ___ ___ / ___ ___
2) Employer:
Provide the following personal information.
1) Name:
3) Email:
2) Phone number:
4) Mailing address:
I am the claimant or claimant’s representative.
If you are the claimant or employer’s representative, identify your
relationship to the party (e.g., Manager, Attorney):
I am the employer or employer’s representative.
Provide your reason for appealing:
Check the box for the decision you want to appeal and provide the requested information.
A. I want to appeal the “Unemployment Insurance Decision.”
1)
Provide the following information from the upper right of the “Unemployment Insurance Decision.”
a)
Last four digits of the claimant’s Social Security Number: X X X – X X – ___ ___ ___ ___
/
/
b)
Original Claim Date: ___ ___
___ ___
___ ___
c)
Two-digit reference number:
R E F = ___ ___
2)
Do you need an interpreter for the appeal hearing?
Yes
No
If you need an interpreter, identify your preferred language of communication:
3)
File your appeal of the “Unemployment Insurance Decision” with the Unemployment Insurance Appeals Bureau:
I o w a W o r k f o r c e D e v e l o p m e n t
FAX
A p p e a l s B u r e a u
- OR -
1 0 0 0 E a s t G r a n d A v e n u e
(5 1 5 ) 4 7 8 -3 5 2 8
D e s M o i n e s , I A 5 0 3 1 9
B. I want to appeal the “Administrative Law Judge Decision.”
1)
Provide the following information from the top of the first page of the “Administrative Law Judge Decision.”
a)
Appeal Number:
X X X – U I – ___ ___ ___ ___ ___ – X X – X
2)
File your appeal of the “Administrative Law Judge Decision” with the Employment Appeal Board:
E m p l o y m e n t A p p e a l B o a r d
FAX
L u c a s S t a t e O f f i c e B u i l d i n g
- OR -
F o u r t h F l o o r
(5 1 5 ) 281-7191
D e s M o i n e s , I A 5 0 3 1 9
Signature
Date
F O R A G E N C Y U S E O N L Y
Unemployment Insurance Appeal Form
Date received (if no postmarked envelope):
F
6 0 - 0 1 6 9 ( 0 2 - 1 6 ) 3 0 9 0 6 0 4
O R M
Claimstaker:
Attention: Unemployment Insurance Appeals Bureau and Employment Appeal Board proceedings are open to the public. This means
that the public and media have access to the hearings, exhibits, transcripts, recordings, and decisions without prior notice to you.
Unemployment Insurance Appeals Bureau decisions are posted online.
Provide the following claim information.
1) Claimant:
3) Other interested party (if applicable):
4) Decision date: ___ ___ / ___ ___ / ___ ___
2) Employer:
Provide the following personal information.
1) Name:
3) Email:
2) Phone number:
4) Mailing address:
I am the claimant or claimant’s representative.
If you are the claimant or employer’s representative, identify your
relationship to the party (e.g., Manager, Attorney):
I am the employer or employer’s representative.
Provide your reason for appealing:
Check the box for the decision you want to appeal and provide the requested information.
A. I want to appeal the “Unemployment Insurance Decision.”
1)
Provide the following information from the upper right of the “Unemployment Insurance Decision.”
a)
Last four digits of the claimant’s Social Security Number: X X X – X X – ___ ___ ___ ___
/
/
b)
Original Claim Date: ___ ___
___ ___
___ ___
c)
Two-digit reference number:
R E F = ___ ___
2)
Do you need an interpreter for the appeal hearing?
Yes
No
If you need an interpreter, identify your preferred language of communication:
3)
File your appeal of the “Unemployment Insurance Decision” with the Unemployment Insurance Appeals Bureau:
I o w a W o r k f o r c e D e v e l o p m e n t
FAX
A p p e a l s B u r e a u
- OR -
1 0 0 0 E a s t G r a n d A v e n u e
(5 1 5 ) 4 7 8 -3 5 2 8
D e s M o i n e s , I A 5 0 3 1 9
B. I want to appeal the “Administrative Law Judge Decision.”
1)
Provide the following information from the top of the first page of the “Administrative Law Judge Decision.”
a)
Appeal Number:
X X X – U I – ___ ___ ___ ___ ___ – X X – X
2)
File your appeal of the “Administrative Law Judge Decision” with the Employment Appeal Board:
E m p l o y m e n t A p p e a l B o a r d
FAX
L u c a s S t a t e O f f i c e B u i l d i n g
- OR -
F o u r t h F l o o r
(5 1 5 ) 281-7191
D e s M o i n e s , I A 5 0 3 1 9
Signature
Date