Fillable Current HHS Poverty Guidelines (Maryland Courts)

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Current HHS Poverty Guidelines (Maryland Courts)

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STATE OF MARYLAND
DEPARTMENT OF LABOR, LICENSING AND REGULATION
DIVISION OF UNEMPLOYMENT INSURANCE
REQUEST RECONSIDERATION OF OVERPAYMENT RECOUPMENT – WAIVER
The Request of Reconsideration of Overpayment Recoupment must be made within thirty (30) days from the date of the
original overpayment notice, unless the claimant can show cause for failure to meet the 30 day requirement.
The Department of Labor, Licensing and Regulation may waive recovery of an Unemployment Insurance (UI)
overpayment when the claimant is found to be without fault and lacks the ability to pay now and in the foreseeable future
or is a part of a household that is below the federal minimum poverty level and likely to remain there for the foreseeable
future.
Current HHS Poverty Guidelines
Persons in Family 48 Contiguous
States and D.C.
Alaska Hawaii
1
$
12,490.00
$1
5,600.00 $14,380.00
2
$16,910.00 $21,130.00 $19,460.00
3
$21,330.00 $26,660.00 $24,540.00
4
$25,750.00 $32,190.00 $29,620.00
5
$30,170.00 $37,720.00 $34,700.00
6
$34,590.00 $43,250.00 $39,780.00
7
$39,010.00 $48,780.00 $44,860.00
8
$43,430.00 $54,310.00 $49,940.00
Fo
r each additional
person above 8, add:
$4,420.00 $5,530.00 $5,080.00
If you m
eet the above criteria, please complete the following to request a waiver of your UI overpayment.
Claimant’s
Name
S.S. No.
Street Address
City, State, Zip
Telephone
Number
Email Address
AFFIDAVIT OF CURRENT INCOME AND LIVING EXPENSES
Average Monthly Household Income
1. Your Current monthly gross income:
Please provide copies of your two (2) most recent paystubs.
Your highest level of education or vocational training completed:
2. Your spouse’s current monthly gross income:
Please provide copies of your spouse’s two (2) most recent pay stubs.
Spouse Name:
Spouse Social Security Number:
3. List names, ages, and Social Security Numbers for all dependents residing in your home (attach additional pages
as necessary):
Name: Age:
SSN: Monthly Gross Income:
Name: Age:
SSN: Monthly Gross Income:
Name: Age:
SSN: Monthly Gross Income:
Name: Age:
SSN: Monthly Gross Income:
Waiver Request
In order for the request for waiver to be approved, you must show lack of ability to pay now and in the foreseeable future.
Please use the space provided below or an attached sheet to indicate what conditions exist that make you unable to repay
your overpayment in the foreseeable future. If reason is due to medical complications, please enclose a medical
statement.
Financial Statement
Other monthly gross income - Please provide copies of your two (2) most recent paystubs for each:
Social Security
Pension and/or Retirement
Severance
Disability
Unemployment Compensation
Alimony
Child Support
TANF/Food Stamps
Other Income (please list)
TOTAL INCOME AND
ASSETS
Monthly Expenses – Please provide supporting documentation for all monthly expenses listed below:
Mortgage/Rent
Second Mortgage
Water
Gas
Electric
Cable
Internet
Medical/Dental
Telephone
Transportation (Car
Payment, fuel, bus, etc.)
Food
Child Care
Student Loan(s)
Credit Card(s)
Home/Renter’s Insurance
Auto Insurance
Health Insurance
Life Insurance
Court ordered support paid
out
Other (please specify)
TOTAL EXPENSES
Bank Accounts - Please attach any additional bank accounts on a separate page.
Name of Bank / Financial Institution:
Bank / Financial Institution Address:
Type of Account: Checking Savings Certificate of Deposits Other:
Account Number: Value of Account:
Name of Bank / Financial Institution:
Bank / Financial Institution Address:
Type of Account: Checking Savings Certificate of Deposits Other:
Account Number: Value of Account:
Name of Bank / Financial Institution:
Bank / Financial Institution Address:
Type of Account: Checking Savings Certificate of Deposits Other:
Account Number: Value of Account:
Name of Bank / Financial Institution:
Bank / Financial Institution Address:
Type of Account: Checking Savings Certificate of Deposits Other:
Account Number: Value of Account:
CERTIFICATION AND SIGNATURE
I understand that it is a criminal offense to make false statements and certify that my answers to the questions on this form
are true. Failure to answer the questions truthfully may be considered unemployment insurance fraud.
I AFFIRM, UNDER THE PENALTIES OF PERJURY, THAT THE INCOME, EXPENSES, AND
INFORMATION LISTED ON THIS FORM ARE ACCURATE AND CORRECT.
Claimant’s Signature: Date:
When you have completed this form, please mail it and all attachments you wish to present to the following address:
Department of Labor, Licensing and Regulation
ATTN: Benefit Payment Control
1100 North Eutaw Street, Room 206
Baltimore, MD 21201
(410) 767-2404
MAIL COMPLETED FORM TO THE ABOVE ADDRESS WITHIN 30 DAYS.
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Current HHS Poverty Guidelines (Maryland Courts)

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Completed 26 April 2021

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