Fillable Form 441: DISTRICT OF COLUMBIA OFFICE OF ADMINISTRATIVE (Government of the District of Columbia)

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Form 441: DISTRICT OF COLUMBIA OFFICE OF ADMINISTRATIVE (Government of the District of Columbia)

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UI Form, Rev. 05-20
DISTRICT OF COLUMBIA
OFFICE OF ADMINISTRATIVE HEARINGS
ONE JUDICIARY SQUARE
441
4TH STREET NW, SUITE 450N
W
ASHINGTON, DC 20001
Tel: (202) 442-9094 Fax: (202) 442-4789
Email: oah.filing@dc.gov
UNEMPLOYMENT INSURANCE APPEAL FORM
Use this form to request a hearing before an Administrative Law Judge if you wish to appeal a decision of the
Department of Employment Services (“DOES”) concerning unemployment insurance benefits.
READ INSTRUCTIONS HERE AND ON THE REVERSE SIDE
For Help and Information, call (202) 442-9094
1. Please submit with this form a copy of the Claims Examiner’s Determination or other DOES decision you are
appealing. You may submit this form first, but we cannot schedule a hearing or proceed with your case until you
submit a copy of the DOES decision you are appealing.
2. Claimants must continue to file claim forms with DOES, even while their appeals are pending in the Office of
Administrative Hearings. Claimants who do not file claim forms as instructed by DOES may lose benefits.
3. Save the envelope in which you received the DOES decision you are appealing. Bring the envelope to the hearing.
It may help show that you filed your appeal on time.
4. Complete the following for CLAIMANT or EMPLOYER, and sign below.
CHECK ONE: I AM: THE CLAIMANT
Claimant
’s Name:_______________________________
Soc. Sec. No. (last four digits): XXX-XX-_____________
Representative (if
any):____________________________
Claimant
’s FULL Address (with unit number, zip code):
_________________________________________
______
___________________________________________
____
Claimant
’s Telephone:____________________________
Cla
imant’s Email:__________________________________
*
Do you consent to service by email? Yes
No
If you most recently worked for the DC Government,
state the agency, department or office for which you
worked: ______________________________________
In addition to the attorneys listed in the attached
documents, law students may be available to provide
free legal assistance to claimants in DOES cases.
Would you like us to share your contact information
with a law school clinic for the purpose of
representing you in your case? Yes No
OR THE EMPLOYER
Employer’s Name:_________________________________
Representative (if any):_____________________________
_
Employer’s/Rep.’s FULL Ad
dress (with unit number, zip
code):
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Employer’s/Rep.’s Telephone:______________________
Employer’s/Rep.’s Fax:____________________________
Employer’s/Rep.’s Email: __________________________
*
N oDo you consent to service by email? Yes
Claimant: Are you self-employed? Yes No
YOUR REASON FOR
FILING APPEAL:__________________________________________________________________
Will you need an INTERPRETER for the hearing? If so, what LANGUAGE? ___________________________________
YOUR SIGNATURE: _________________________________________
TURN OVER FOR MORE INSTRUCTIONS
    
UI Form, Rev. 05-20
UNEMPLOYMENT INSURANCE APPEAL FORM, PAGE 2
ADDITIONAL INSTRUCTIONS
• WHERE TO FILE: You MUST file your appeal with the Office of Administrative Hearings. The Office of
Administrative Hearings (“OAH”) is not part of the Department of Employment Services. You cannot file your
appeal at a DOES One-Stop Center or any other DOES office.
You may file an appeal by mail, in person, by fax or by email:
By Mail or In Person. You may file an appeal in person, weekdays between 9:00 a.m. and 5:00 p.m.
You will need photo identification to enter the building. You may file an appeal by mail at the following
address:
Office of Administrative Hearings
One Judiciary Square
441 Fourth Street, NW, Suite 450 North
Washington, DC 20001-2714
By Fax. You may file an appeal by fax to (202) 442-4789. If possible, please include a copy of the
Claims Examiner’s Determination or other written decision you are appealing. Faxes received after 5:00
p.m. or on any non-business day are considered “filed” on the next business day. An appeal sent by fax
will not be filed unless it is complete and legible when received.
By Email. You may file an appeal by email to OAH.FILING@DC.GOV. If possible, please attach a
scanned copy of the Claims Examiner’s Determination or other written decision you are appealing.
• APPEAL DEADLINE: Your appeal must be either postmarked by the U.S. Postal Service (not a private postage
meter) or actually received by the Office of Administrative Hearings within fifteen (15) calendar days of the date
DOES mailed the Claims Examiner’s Determination to you. The date of mailing is usually stated on the Claims
Examiner’s Determination. The deadline runs from the date DOES mailed the Determination to you, not from the
date you received it. If the Claims Examiner’s Determination was NOT mailed to you, or if was not mailed to
your correct address, you must file within fifteen (15) calendar days of actual delivery of the Claims Examiner’s
Determination.
If the 15-calendar-day filing deadline falls on a Saturday, Sunday or a legal holiday, the deadline is extended to
the next business day.
The appeal deadline may be extended if an administrative law judge finds “good cause” or “excusable neglect”
for a delay. The person filing the appeal bears the burden of proving at the hearing that there was a good reason
for the delay. If you file an appeal late without a good reason, your case may be dismissed.
No one is authorized to give you different instructions about the deadline.
• RULES: The Rules of Procedure for the Office of Administrative Hearings may be found at www.oah.dc.gov
and in the Office of Administrative Hearings Resource Center.
Please note: *By checking the YES box, I consent, according to OAH Rule 2841.16, to receive orders or any
other documents issued in this case by email.
• FURTHER INFORMATION: For further information about this document or filing an appeal, please call (202)
442-9094 or visit the Office of Administrative Hearings weekdays from 9:00 a.m. to
5:00 p.m., One Judiciary Square, 441 Fourth Street, NW, Suite 450 North, Washington, DC 20001-2714.
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Form 441: DISTRICT OF COLUMBIA OFFICE OF ADMINISTRATIVE (Government of the District of Columbia)

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Completed 7 August 2021

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