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GOVERNMENT OF THE DISTRICT OF COLUMBIA Department of (Government of the District of Columbia)

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BROWSE GOVERNMENT OF THE DISTRICT OF COLUMBIA (DC) FORMS

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GOVERNMENT OF THE DISTRICT OF COLUMBIA
Department of Employment Services
MURIEL BOWSER
MAYOR
DR. UNIQUE MORRIS-HUGHES
INTERIM DIRECTOR
4058 Minnesota Ave, N.E. • Suite 5000 • Washington, D.C. 20019 • Office: 202.671.1900
REQUEST FOR WAIVER OF OVERPAYMENT
D.C. Code § 51-119 provides that the Director of the Department of Employment Services
(DOES) may waive an Unemployment Insurance (UI) overpayment if:
1. The overpayment was received without fault on the part of the claimant and
2. Recoupment of the overpayment would be against equity and good conscience.
Please be aware that fraud overpayments cannot be waived.
In order to determine whether a waiver should be granted, you must provide certain facts and
evidence concerning your financial status and the cause of the overpayment. If DOES determines
that a waiver should be granted, you will not be required to repay the overpayment. If DOES
determines that a waiver should be denied, you will be required to repay the overpayment.
If you wish to request a waiver of your overpayment, you must complete, sign and return this
Request for Waiver of Overpayment and your supporting documentation to the address
shown below within 30 calendar days from the date of the original Notice of Determination
of Overpayment, unless you can show good cause for failure to meet the 30 calendar day
requirement.
Benefit Payment Control
4058 Minnesota Avenue NE
Suite 3100
Washington, DC 20019
If you have questions about this application, please contact Benefit Payment Control at 202-698-
5111.
REQUEST FOR WAIVER OF OVERPAYMENT
Failure to provide the information requested in this application will result in the denial of
your request to waive your overpayment.
Claimant Name: ________________________________________________________________
Social Security Number: _________________________________________________________
Address: ______________________________________________________________________
City, State, Zip: ________________________________________________________________
Telephone Number: _____________________ Cell Phone Number: _______________________
Email Address: _________________________________________________________________
Section 1. Household Income
1. Your current monthly gross income: $__________________
Please provide copies of your two (2) most recent pay stubs.
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
Name: __________________________________________________ Age: ____________
Social Security Number: _____________________ Monthly Gross Income: $___________
Name: __________________________________________________ Age: ____________
Social Security Number: _____________________ Monthly Gross Income: $___________
Name: __________________________________________________ Age: ____________
Social Security Number: _____________________ Monthly Gross Income: $___________
Name: __________________________________________________ Age: ____________
Social Security Number: _____________________ Monthly Gross Income: $___________
4. Other monthly gross income:
Please provide copies of your two (2) most recent pay stubs for each.
Social Security
$
Pension
$
Severance
$
Disability
$
Unemployment Compensation
$
Alimony
$
TANF/Food Stamps
$
Other Income (please list)
________________________________
________________________________
________________________________
________________________________
$_________________
$_________________
$_________________
$_________________
Section 2. Monthly Expenses
Please provide any supporting documentation for the monthly expenses listed below.
Mortgage/Rent
$
Home/Renter’s Insurance
$
Water
$
Gas
$
Electric
$
Cable
$
Internet
$
Telephone/Cell Phone
$
Transportation
$
Food
$
Child Care
$
Student Loan(s)
$
Credit Card(s)
$
Auto Insurance
$
Health Insurance
$
Life Insurance
$
Other (please list)
________________________
________________________
_______________________
$__________________
$__________________
$__________________
Section 3. Personal Statement
1. Please explain why you believe that you were not at fault in causing the overpayment.
2. Please explain why you believe that it would be unfair for you to have to repay the
overpayment.
3. If required to repay the overpayment, how much can you pay per month?
Section 4. Affirmation
I hereby request a waiver of my overpayment. I affirm that the income and expenses listed on
this application are accurate and correct. I understand that in order to be considered for a waiver
of my overpayment, I must return the completed and signed application and all supporting
documentation within 30 calendar days from the date of the original Notice of Determination of
Overpayment. I also understand that failure to provide the information requested in this
application will result in the denial of this request to waive my overpayment.
____________________________________ __________________
Claimant Signature Date
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GOVERNMENT OF THE DISTRICT OF COLUMBIA Department of (Government of the District of Columbia)

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Completed 8 August 2021

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