DEOI Form A100 RAAC(E) "Reemployment Assistance Appeals Commission Request for Review" - Florida

What Is DEOI Form A100 RAAC(E)?

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

Form Details:

  • Released on April 1, 2012;
  • The latest edition provided by the Florida Department of Economic Opportunity;
  • 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 DEOI Form A100 RAAC(E) by clicking the link below or browse more documents and templates provided by the Florida Department of Economic Opportunity.

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Download DEOI Form A100 RAAC(E) "Reemployment Assistance Appeals Commission Request for Review" - Florida

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REEMPLOYMENT ASSISTANCE APPEALS COMMISSION
REQUEST FOR REVIEW
NOTICE:
Appeals cannot be filed at a local “one-stop” office.
The Reemployment Assistance Appeals
Commission will not hold a hearing. This form is not intended for use in filing an appeal with a District Court
of Appeal.
PLEASE PROVIDE THE FOLLOWING INFORMATION:
Claimant Name:
Address: _____________________________________________________________________________
City: ________________________________________ State: _________ Zip: _____________________
Social Security Number Last Four Digits*: _____________________________
Employer Name (if applicable): ________________________________________________________
Account Number (if known): __________________________________________________________
Address: _________________________________________________________________________
City: ________________________________________ State: _________ Zip: __________________
Contact Person: _______________________________ Telephone: ___________________________
REPRESENTATIVE – If you are filing on behalf of a party, provide the following:
Name of Representative: ________________________________________________________
Address: _____________________________________________________________________
City: ________________________________ State: _________ Zip: _____________________
Contact Person: _______________________ Telephone: ______________________________
I AM APPEALING REFEREE DECISION NO. ______________, DATED _________
I appeal because:
Important
: If you did not attend the referee’s hearing, you must explain your nonappearance.
( ) I did not attend the hearing because:
Important
: Late appeals are subject to dismissal. If your appeal is not being filed within 20 calendar days of the
mailing date of the referee’s decision, you must explain why your appeal is late. Parties are urged to contact the
REEMPLOYMENT ASSISTANCE APPEALS COMMISSION (850-487-2685) to verify that the faxed appeal was
received.
( ) My appeal is late because:
Signature: ______________________ ______Print Name:_ ______________Date:
________________
I am: ( ) the claimant; ( ) the claimant’s representative; ( ) the employer; ( ) the employer’s representative
MAIL OR FAX THIS FORM TO:
Reemployment Assistance Appeals Commission
Suite 101, Rhyne Building
2740 Centerview Drive
Tallahassee, Florida 32399-4151
Fax: (850) 488-2123
*PRIVACY ACT STATEMENT
Information provided to the Reemployment Assistance Appeals Commission is voluntary and confidential but is required to process claims.
Pursuant to the Internal Revenue Code of 1986, the Social Security Act, 42 U.S.C. 1320b-7(a)1, and s. 443.091(1)(h), F.S., disclosure of Social
Security numbers is mandatory when requested by the Commission. Social Security numbers will be used to ensure unemployment benefits
have been properly paid, to report benefits received to the Internal Revenue Service as potential taxable income, and for statistical and research
purposes. In accordance with the Federal Deficit Reduction Act, an amendment to the Federal Social Security Act, and 5 U.S.C. 552a(o)(1)(D),
information provided is subject to verification through computer matching programs and information about wages and claims may be provided to
other federal, state and local agencies or their contractors for verification of eligibility under other government programs to ensure benefits have
been properly paid and for statistical and research purposes.
An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with
disabilities.
Form: Reemployment Assistance Appeals Commission Request For Review
Rule 73B-21.002
Form # DEO– A100 RAAC(E) (4/12)
REEMPLOYMENT ASSISTANCE APPEALS COMMISSION
REQUEST FOR REVIEW
NOTICE:
Appeals cannot be filed at a local “one-stop” office.
The Reemployment Assistance Appeals
Commission will not hold a hearing. This form is not intended for use in filing an appeal with a District Court
of Appeal.
PLEASE PROVIDE THE FOLLOWING INFORMATION:
Claimant Name:
Address: _____________________________________________________________________________
City: ________________________________________ State: _________ Zip: _____________________
Social Security Number Last Four Digits*: _____________________________
Employer Name (if applicable): ________________________________________________________
Account Number (if known): __________________________________________________________
Address: _________________________________________________________________________
City: ________________________________________ State: _________ Zip: __________________
Contact Person: _______________________________ Telephone: ___________________________
REPRESENTATIVE – If you are filing on behalf of a party, provide the following:
Name of Representative: ________________________________________________________
Address: _____________________________________________________________________
City: ________________________________ State: _________ Zip: _____________________
Contact Person: _______________________ Telephone: ______________________________
I AM APPEALING REFEREE DECISION NO. ______________, DATED _________
I appeal because:
Important
: If you did not attend the referee’s hearing, you must explain your nonappearance.
( ) I did not attend the hearing because:
Important
: Late appeals are subject to dismissal. If your appeal is not being filed within 20 calendar days of the
mailing date of the referee’s decision, you must explain why your appeal is late. Parties are urged to contact the
REEMPLOYMENT ASSISTANCE APPEALS COMMISSION (850-487-2685) to verify that the faxed appeal was
received.
( ) My appeal is late because:
Signature: ______________________ ______Print Name:_ ______________Date:
________________
I am: ( ) the claimant; ( ) the claimant’s representative; ( ) the employer; ( ) the employer’s representative
MAIL OR FAX THIS FORM TO:
Reemployment Assistance Appeals Commission
Suite 101, Rhyne Building
2740 Centerview Drive
Tallahassee, Florida 32399-4151
Fax: (850) 488-2123
*PRIVACY ACT STATEMENT
Information provided to the Reemployment Assistance Appeals Commission is voluntary and confidential but is required to process claims.
Pursuant to the Internal Revenue Code of 1986, the Social Security Act, 42 U.S.C. 1320b-7(a)1, and s. 443.091(1)(h), F.S., disclosure of Social
Security numbers is mandatory when requested by the Commission. Social Security numbers will be used to ensure unemployment benefits
have been properly paid, to report benefits received to the Internal Revenue Service as potential taxable income, and for statistical and research
purposes. In accordance with the Federal Deficit Reduction Act, an amendment to the Federal Social Security Act, and 5 U.S.C. 552a(o)(1)(D),
information provided is subject to verification through computer matching programs and information about wages and claims may be provided to
other federal, state and local agencies or their contractors for verification of eligibility under other government programs to ensure benefits have
been properly paid and for statistical and research purposes.
An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with
disabilities.
Form: Reemployment Assistance Appeals Commission Request For Review
Rule 73B-21.002
Form # DEO– A100 RAAC(E) (4/12)