Fillable Employer Request For An Appeal Of Unemployment Insurance Benefits Determination (Missouri)

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Employer Request For An Appeal Of Unemployment Insurance Benefits Determination (Missouri)

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MODES-4792 (01-17) AI
Appeals
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
EMPLOYER REQUEST FOR AN APPEAL OF
UNEMPLOYMENT INSURANCE BENEFITS
DETERMINATION
Your Name
Job Title
Name of Business
Date of Determination
Name of Claimant (Use one Appeal form per claimant)
Claimant Social Security Number
Mo. Unemployment Tax Account Number
I appeal this determination. Brief statement explaining why:
Date
Signature
Mail to: Fax to:
Division of Employment Security 573-751-1321
Appeals Tribunal
P.O. Box 59
Jefferson City, MO 65104
IMPORTANT: If needed, call 573-751-3913 for assistance in the translation and understanding of the
information in this document.
¡IMPORTANTE!: Si es necesario, llame al 573-751-3913 para asistencia en la traducción y
entendimiento de la información en este documento.
Missouri Division of Employment Security is an equal opportunity employer/program. Auxiliary aids and services
are available upon request to individuals with disabilities. TDD/TTY: 800-735-2966 Relay Missouri: 711
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Employer Request For An Appeal Of Unemployment Insurance Benefits Determination (Missouri)

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Completed 5 August 2020

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