TELEPHONE: 603-223-6125 FAX 603-223-6137 TTD ACCESS: RELAY NH 1-800-735-2964
NHDES is an Equal Opportunity Employer and complies with the American With Disabilities Act
Instructions for Request for Withdrawal of NH Unemployment Claim
Section I. Fill in the contact inform
ation. Include your first name
, last name, social security number
(SSN), mailing address, city, state and zip code.
2) Check the Reason for Withdrawal box to identify why you are withdrawing your unem
Severance pay, vacation pay, or any monies that you may have received (other than wages)
from your last employer. (Skip Section II)
Other (Please specify): _________________________________________________ (Skip Section II)
Want to file in another State/Combined Wage Claim (Please Complete Section II)
Help: If you received wages in m
ore than one state you are eligible to file against a state different
than NH. Checking the last box indicates your desire to claim benefits against a state
other than NH.
Example: Going forward, you want to file your unemployment claim in Maine. Enter Maine in the space
provided. This m
eans that you will no longer be filing your weekly claims in New Hampshire
and the wages you received in other states will be counted as part of your claim in Maine.
Section II. Skip this section if you are not filing a combined wage claim in another state.
If you are filing a combined wage claim in another state, you must complete Section II
of this form.
First, you need to write or print the state in which you wish to f
ile your unemployment claim in
the space provided.
Second, you m
ust choose whether you have or have not received benefits for having a combined
wage claim filed in New Hampshire
you have received benefits, you must select whether you are choosing to repay New Hampshire
for the overpayment of benefits you have received as part of a combined wage claim in this state
or whether you are choosing to have the new claim state collect payment to give to
New Hampshire for an overpayment of benefits.
1) I would like to file m
y claim in the state of: Maine
2) I have not received any unemployment insurance benefits as a result of my New Hampshire
I have received unemployment insurance benefits from my New Hampshire combined-wage
I am immediately repaying the State of New Hampshire (attach check or money
Payable to "NHUCB Account") in the amount of: $ 1,500.00
I agree to have the other State recover the amount of the Overpayment.
Sign and date the form in the fields provided. The form must be received by mail, fax, or in person within
seven (7) days of your discussion with the NHES Wage Unit at the address on the top of the form.
New Hampshire Employment Security
Special Programs Unit
45 South Fruit Street, Concord, NH 03301
Fax (603) 223-6137