PETITION FOR APPEAL
TO APPEAL TRIBUNAL
DWS-ARK-AT-213 v08232019
ARKANSAS APPEAL TRIBUNAL
Post Office Box 8013
Little Rock, AR 72203
Page of
ALL ENTRIES ON THIS FORM EXCEPT SIGNATURES SHOULD BE PRINTED OR TYPED
1.
CLAIMANT'S FIRST NAME:
2.
SOCIAL SECURITY NUMBER: BENEFIT YEAR:CLAIMANT'S LAST NAME:
3.
ADDRESS: (STREET OR BOX NUMBER):
(CITY):
(STATE): (ZIP CODE):
4.
TELEPHONE NUMBER:
5. ISSUE(S) APPEALED:
Section(s):
6.
I / We appeal from the determination of the Division of Workforce Services for the following reason(s)
(Please attach a copy of the determination):
7.
APPELLANT SIGNATURE:
8. APPELLANT (CHECK ONE):
Claimant Employer
NOTE TO CLAIMANT FROM DWS: To protect your potential rights to benefits, you must continue filing a claim each week,
making your work search as instructed, and reporting to your local office as directed during the time your appeal is pending
unless you are working full-time.
QUESTIONS BELOW ARE FOR LOCAL OFFICE USE ONLY
9. Agency Representative To Testify? (CHECK ONE)
Yes No
If Yes,
(Name) (Title)
11. APPEAL FILED:
(A) In person on
(Date)
(B) By mail
(Postmark Date) (Attach Envelope)
Phone Number:
10. TYPE OF CLAIM:
UI UCFE UCX EB TRA OTHER
12. EMPLOYER PHONE NUMBER:
14.
APPEAL RECEIVED BY: (INTERVIEWER):
13. EMPLOYER ADDRESS CONFIRMATION (CHECK ONE):
A. Are employer name and address on the Determination complete and correct?
If no, enter the complete name and mailing address in the space indicated below.
B. Are employer name and address omitted from the Determination?
If yes, enter the complete name and mailing address in the space indicated below
Yes No
Yes No
PHONE NUMBER:
ADDRESS:
CITY:
STATE:
15. LOCAL OFFICE ADDRESS:
16.
EMPLOYER ADDRESS CORRECTION:
ZIP CODE:
NAME OF EMPLOYER:
ADDRESS:
CITY: STATE:
ZIP CODE:
