This appeal form may be used to appeal an adverse determination made by a Reemployment Assistance adjudication examiner regarding your Reemployment Assistance Benefits. A separate appeal must be filed for each adverse determination made by an adjudicator examiner.

After you submit your appeal request and the request is processed by the Reemployment Assistance Appeals team, you will receive additional correspondence regarding your appeal in your CONNECT inbox.

NOTICE TO CLAIMANTS: You must continue claiming your Reemployment Assistance Benefits until a decision has been rendered; otherwise, additional Reemployment Assistance Benefits may not be paid.

This form may not be used to submit any other type of correspondence or request to the Florida Department of Economic Opportunity.

For more information regarding Reemployment Assistance eligibility and qualification, please view the Reemployment Assistance Handbook or the Reemployment Assistance Resources.

 

Appeal Filing Form

Required fields are indicated with  *.

(?)
Your Issue Identification Number may be found on the top center of the Notice of Disqualification.
(?)
The distribution date is the date the notice of disqualification was mailed.

CONTACT INFORMATION

(?)

Contact Numbers

 * Preferred Contact


* Are you the claimant?

If you are not the claimant, enter the claimant’s information below.

.

Appeals MUST be filed within 20 calendar days of the determination date. If you are submitting your appeal outside of that time frame, state the reason for late filing. Use the fields below to describe, using specific facts, the reason you disagree with the information in the determination.
* Is your appeal late?

(?)
This answer is required to submit form

HEARING DETAILS

 *  Will you be represented by an attorney or other authorized representative?


* If you selected yes, enter the representative’s information below.
 *  Do you expect to call a witness to testify?


* If you expect to call a witness to testify then please provide the information below.
 *  Will you require an interpreter?

 *  Do you want to add a temporary mailing address?

* If you want to add a temporary mailing address then please provide the information below.

For more information regarding the hearing process, instructions on how to request a subpoena or submit documents/exhibits for the hearing please visit FloridaJobs.com for FAQ.

The Office of Appeals generally schedules appeal cases in the order received. Once your case is scheduled, a Notice of Hearing will be distributed to you either by mail or electronically; depending on the method of communication you selected in your CONNECT account.

Type your name into the signature box to affix your electronic signature on this form.
.
.
 

.
PRIVACY ACT STATEMENT 
Information you provide to this department is voluntary and confidential but is required to process your claim. Pursuant to the Internal Revenue Code of 1986, the Social Security Act, 42 U.S.C. 1320b-7(a)1, and s. 443.091(1)(h), F.S., disclosure of your Social Security number is mandatory. Social Security numbers will be used by the department to report the benefits you receive to the Internal Revenue Service as potential taxable income. In accordance with the Federal Deficit Reduction Act, an amendment to the Federal Social Security Act, and 5 U.S.C. 552a(o)(1)(D), information you provide is subject to verification through computer matching programs and information about your wages and claim may be provided to other federal, state and local agencies or their contractors for verification of eligibility under other government programs to ensure benefits have been properly paid and for statistical and research purposes. 
An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. 
Form: Notice of Appeal 
Form # DEO – A100(E) (11/18) 
Rule 73B-20.003, F.A.C.
 
An equal opportunity employer/program.  Auxiliary aids and services are available upon request to individuals with disabilities.
All voice telephone numbers on this website may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.
You have selected a link to a website that is outside of the floridajobs.org domain. Control of the content of this website belongs to the website's owner and not to the Department of Economic Opportunity.
OK
 
Cancel