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Uiopwaiver 263

The document provides instructions for requesting a waiver of an unemployment insurance overpayment in Maryland, noting that the request must be made within 30 days unless cause for delay is shown. A waiver may be granted if the claimant is found to be without fault for the overpayment and lacks ability to repay now or in the foreseeable future. Claimants must complete an affidavit detailing their income, expenses, bank accounts, and reason for inability to repay to apply for a waiver.

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107 views5 pages

Uiopwaiver 263

The document provides instructions for requesting a waiver of an unemployment insurance overpayment in Maryland, noting that the request must be made within 30 days unless cause for delay is shown. A waiver may be granted if the claimant is found to be without fault for the overpayment and lacks ability to repay now or in the foreseeable future. Claimants must complete an affidavit detailing their income, expenses, bank accounts, and reason for inability to repay to apply for a waiver.

Uploaded by

mike_mckeown_3
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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STATE OF MARYLAND

DEPARTMENT OF LABOR, LICENSING AND REGULATION


DIVISION OF UNEMPLOYMENT INSURANCE

REQUEST RECONSIDERATION OF OVERPAYMENT RECOUPMENT – WAIVER

The Request of Reconsideration of Overpayment Recoupment must be made within thirty (30) days from the date of the
original overpayment notice, unless the claimant can show cause for failure to meet the 30 day requirement.

The Department of Labor, Licensing and Regulation may waive recovery of an Unemployment Insurance (UI)
overpayment when the claimant is found to be without fault and lacks the ability to pay now and in the foreseeable future
or is a part of a household that is below the federal minimum poverty level and likely to remain there for the foreseeable
future.

Current HHS Poverty Guidelines


Persons in Family 48 Contiguous Alaska Hawaii
States and D.C.
1 $12,490.00 $15,600.00 $14,380.00

2 $16,910.00 $21,130.00 $19,460.00

3 $21,330.00 $26,660.00 $24,540.00

4 $25,750.00 $32,190.00 $29,620.00

5 $30,170.00 $37,720.00 $34,700.00

6 $34,590.00 $43,250.00 $39,780.00

7 $39,010.00 $48,780.00 $44,860.00

8 $43,430.00 $54,310.00 $49,940.00


For each additional
$4,420.00 $5,530.00 $5,080.00
person above 8, add:

If you meet the above criteria, please complete the following to request a waiver of your UI overpayment.

Claimant’s
Name

S.S. No.

Street Address

City, State, Zip

Telephone
Number

Email Address
AFFIDAVIT OF CURRENT INCOME AND LIVING EXPENSES

Average Monthly Household Income

1. Your Current monthly gross income:


Please provide copies of your two (2) most recent paystubs.

Your highest level of education or vocational training completed:

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 (attach additional pages
as necessary):
Name: Age:

SSN: Monthly Gross Income:

Name: Age:

SSN: Monthly Gross Income:

Name: Age:

SSN: Monthly Gross Income:

Name: Age:

SSN: Monthly Gross Income:

Waiver Request

In order for the request for waiver to be approved, you must show lack of ability to pay now and in the foreseeable future.
Please use the space provided below or an attached sheet to indicate what conditions exist that make you unable to repay
your overpayment in the foreseeable future. If reason is due to medical complications, please enclose a medical
statement.
Financial Statement

Other monthly gross income - Please provide copies of your two (2) most recent paystubs for each:

Social Security

Pension and/or Retirement

Severance

Disability

Unemployment Compensation

Alimony

Child Support

TANF/Food Stamps

Other Income (please list)

TOTAL INCOME AND


ASSETS

Monthly Expenses – Please provide supporting documentation for all monthly expenses listed below:

Mortgage/Rent

Second Mortgage

Water

Gas

Electric

Cable

Internet

Medical/Dental

Telephone

Transportation (Car
Payment, fuel, bus, etc.)
Food

Child Care
Student Loan(s)

Credit Card(s)

Home/Renter’s Insurance

Auto Insurance

Health Insurance

Life Insurance

Court ordered support paid


out
Other (please specify)

TOTAL EXPENSES

Bank Accounts - Please attach any additional bank accounts on a separate page.

Name of Bank / Financial Institution:


Bank / Financial Institution Address:
Type of Account: Checking Savings Certificate of Deposits Other:
Account Number: Value of Account:

Name of Bank / Financial Institution:


Bank / Financial Institution Address:
Type of Account: Checking Savings Certificate of Deposits Other:
Account Number: Value of Account:

Name of Bank / Financial Institution:


Bank / Financial Institution Address:
Type of Account: Checking Savings Certificate of Deposits Other:
Account Number: Value of Account:

Name of Bank / Financial Institution:


Bank / Financial Institution Address:
Type of Account: Checking Savings Certificate of Deposits Other:
Account Number: Value of Account:
CERTIFICATION AND SIGNATURE

I understand that it is a criminal offense to make false statements and certify that my answers to the questions on this form
are true. Failure to answer the questions truthfully may be considered unemployment insurance fraud.

I AFFIRM, UNDER THE PENALTIES OF PERJURY, THAT THE INCOME, EXPENSES, AND
INFORMATION LISTED ON THIS FORM ARE ACCURATE AND CORRECT.

Claimant’s Signature: Date:

When you have completed this form, please mail it and all attachments you wish to present to the following address:

Department of Labor, Licensing and Regulation


ATTN: Benefit Payment Control
1100 North Eutaw Street, Room 206
Baltimore, MD 21201
(410) 767-2404

MAIL COMPLETED FORM TO THE ABOVE ADDRESS WITHIN 30 DAYS.

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