NEW YORK STATE DEPT OF LABOR

PO BOX 15130
ALBANY NY 12212-5130 EFF. DT. 02/03/2020 LO# 0831 1
SOC. SEC. NO.: XXX-XX-
680-43-5671
ER NO. E00-00000  
Mail Date: July 21, 2020

ISMAIL   AHMED
1942 BRONXDALE AVE
     
BRONX NY 10462-3355

Dear ISMAIL   AHMED,

The Department of Labor has received information that you were offered employment by TYPE EMPLOYER
NAME HERE, which you refused. In order to make a determination on this claim, we need specific
information from you
.

Please complete the attached questionnaire and return it immediately.  If we do not receive your
response within seven (7) calendar days from the mailing date listed above, a determination will be
made based upon available information.

Return the questionnaire by choosing one of the options below:

• Online: Log in at www.labor.ny.gov/signin. Select “Go to My Inbox” and then “Compose New.”
Select “Submit Documents” for the first subject line and “Return Completed Questionnaire” for
the second subject line. Select “Attach File” and upload a digital copy of your documents. Then
select “Send”.
• Fax it to (518) 457-9492. If you do not have access to a fax machine, visit the Resource Room
at your New York State Career Center. To find the closest Career Center, go to
www.labor.ny.gov/career-center-locator/ or call (888) 469-7365.
• Mail it to the above address.

Please answer all questions and write only in the space provided. If you need more space, attach extra
pages using 8 ½ x 11-inch paper. Include your full name and full Social Security number on every page
you send. The review process usually takes three to six weeks from the date we receive your response. It
may take longer in certain circumstances.

You must continue to claim weekly benefits while we review your claim if you remain unemployed and
are seeking benefits. You can claim benefits on our website, www.labor.ny.gov/signin. You may also call
toll-free to (888) 581-5812.
 Important: If we decide that you are not eligible for benefits, you will receive a Notice of Determination in the
mail explaining why. You may be required to repay benefits that you were not entitled to receive. You may also
have to pay added penalties and forfeit future benefits if you made false statements to get benefits. 

If you disagree with any determination you receive, you have a right to a hearing before an administrative
law judge at no cost or obligation to you.

Failure to repay any benefits that you receive improperly may result in the Department of Labor taking legal action
to file a judgment against you. Once entered, a judgment is good and can be used against you for 20 years. Your
money, including a portion of your paycheck and/or bank account, may be taken. A judgment may also hurt your
credit score and can affect your ability to rent a home, find a job, or take out a loan.

For the Commissioner of Labor,

By:

BCFDMS

EFF. DT. LO# 0831 1

Second Page SOCIAL SECURITY NO. 680-43-5671
Mail Date: July 21, 2020 ER NO. E00-00000  
The Department of Labor has received information indicating that you refused an offer of work by
TYPE EMPLOYER NAME HERE, during a week you claimed unemployment insurance benefits.

1. Did you refuse an offer of work from the employer shown above?
YES: Continue and answer ALL questions, sign and return this questionnaire.
NO: GOTO to question 13, answer remaining questions, sign and return this questionnaire.

2. On what date did you receive this      

offer?

3. What was the title of the position      

offered?

4. How did the employer make this offer of employment to you?

In-person Telephone Letter Other:      

5. What is the name, title and phone number of the person who offered you work?
Name:       Title:      
Tel. #:      

6. What was the work schedule (hours and days per week) of the position offered?
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
 Start Time                                          
End Time                                          

7. What was the rate of $       per      

pay?

8. What is the street address of the offered position?

Street:      
City:       State:    ZIP:      

9. Have you performed this type of work before?

YES NO
If “YES”, please answer the following questions.
a. When?      
b. For this employer?
YES NO

10. Where were you living at the time you were offered this position?
Street:      
City:       State:    ZIP:      

BCFDMS

EFF. DT. LO# 0831 1

Third Page SOCIAL SECURITY NO. 680-43-5671
Mail Date: July 21, 2020 ER NO. E00-00000  

11. Why did you refuse this employer’s offer of work?

______________________________________________________________________________
______________________________________________________________________________

12. Did you inform the employer that you were refusing their offer of employment?

YES NO
If “YES”, please answer the following questions.
a. Who did you inform?
Name:       Title:      
Tel. #:      
b. On what date did you inform the employer?      
c. How did you inform the employer?
 Telephone Letter (please supply a copy) In-person
d. What reason did you give the employer for refusing their offer of employment?
____________________________________________________________________________________
________________________________________________________________

13. Answer this question only if the box is checked.

When you certified to benefits for the week ending       on  7/12/2020    , you stated that
you didn’t refuse a job offer or job referral.

Why didn’t you indicate, when you certified for benefits, that you had refused a job offer or job
referral?

I had hastily completed the certification and made a mistake. i haven't been offered jobs. I would
not have refused a job offer. I did not mean to indicate anything to the contrary. My
apologies.______________________________________________________________________
______________________________________________________________________________
________

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Warning: We will determine whether you are eligible for benefits based on information we
receive. If it is determined you are not eligible for benefits, you may be required to repay some
or all of the benefits paid to you.

I certify that these statements are true to the best of my knowledge and I am aware that there are
penalties provided for making false statements and that this form may be used in a hearing involving
my claim.
Signatur Date
e: Ismail Ahmed : 7/20/2020
Phone number where you can be reached between 8 AM and
5 PM: 929-364-9783
Your email
address: [email protected]

Above Information obtained by phone call on      .

BCFDMS