Form UC-2203: Waiver Questionnaire

Form UC-2203: Waiver Questionnaire

State of Connecticut Department of Labor, Employment Securing Adjudications

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Form UC-2203: Waiver Questionnaire >

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At the time the overpayment occurred:
Amount Overpaid:
For office use only.
Two times the WBA:
For office use only.
Please complete all of the following information. Answers to questions should be complete and contain documentation where applicable. The decision rendered will be influenced by your responses to the questions. This form must be completed and submitted prior to your hearing, and should not be discarded.
Waiver Questionnaire

Claimant Questions
Do you have a mental or physical condition, poor health or other circumstances, which will greatly reduce your chances of obtaining future employment?

YesNo
If you have a mental or physical condition, poor health or other circumstances that will greatly reduce your chances of obtaining future employment, please use the space below to explain.
Enter your response in the space above.
If you have a mental or physical condition, poor health or other circumstances that will greatly reduce your chances of obtaining future employment, please attach any medical documentation to support such condition.

If you are submitting a paper version of this form, please attach to this form physical copies of the documents requested above.
Cancelof
Were you overpaid as a result of gross administrative error either by the Unemployment Compensation Department or the Employment Security Appeals Division?

YesNo
If you were overpaid as a result of gross administrative error either by the Unemployment Compensation Department or the Employment Security Appeals Division, please the space below to explain.
Enter your response in the space above.
If you were overpaid as a result of gross administrative error either by the Unemployment Compensation Department or the Employment Security Appeals Division, please attach any documentation to support such error.

If you are submitting a paper version of this form, please attach to this form physical copies of the documents requested above.
Cancelof
Did you not apply for public welfare benefits (for which you would have been entitled) because you received unemployment benefits?

YesNo
An overpayment may be waived in the event of death. As the administrator of the deceased claimant’s estate, are you providing a copy of the death certificate?

YesNo
An overpayment may be canceled in a case of bankruptcy. If you filed for bankruptcy protection naming the Department of Labor as a creditor, are you providing a copy of the court bankruptcy filing?

YesNo
Were you overpaid because the employer failed to provide the Department of Labor information during your hearing before the administrator that resulted in a denial of unemployment insurance benefits?

YesNo
Claimant Name

First NameLast Name
Claimant Social Security Number
Enter the 9 digits of your Social Security Number (SSN).
Please complete the questions below. All income reported below is for the 6 month period prior to the date you have completed this form. You must provide documentation.
Claimant's Gross Income
Includes any wages, disability payments, welfare benefits, pensions, Social Security benefits, and cash contributions from any other source.
Spouse's Gross Income
Includes any wages, disability payments, welfare benefits, pensions, Social Security benefits, and cash contributions from any other source.
Spouse's Social Security Number
Enter your spouse's 9-digit Social Security Number (SSN).
Cash contributions from other family members, whether or not they reside in the household:
Extraordinary medical expenses including dental, not covered by insurance (documentation required):
If you are facing extraordinary medical expenses (including dental, not covered by insurance), please attach any documentation to support such expenses.

If you are submitting a paper version of this form, please attach to this form physical copies of the documents requested above.
Cancelof
Family Size
Please use the space below to enter (1) the first and last names of family members who live with you and/or are financially dependent upon you, (2) their relationship to you, and (3) their Social Security Number.
Enter your response in the space above.
Claimant’s unemployment compensation (less the amount overpaid):
For Office Use Only
Spouse’s unemployment compensation:
Add lines (a) through (e):
Multiply line (f) times 2:
150 % of poverty level for stated family size:
Certification
I certify that the information contained herein is true and correct to the best of my knowledge and belief. I understand that the law provides penalties for making false statements or representations.
Claimant's Signature
Date

MonthDayYear
Claimant Phone Number

Area CodePhone Number
Interviewer Remarks
Should be Empty:

Form UC-2203: Waiver Questionnaire

Print a PDF Version of This Form

At the time the overpayment occurred:

Waiver Questionnaire

For Office Use Only

Certification