Unemployment Benefits Overpayment Waiver Hardship Form
Applicant Information
Full Name
Last 4 digits of SSN
Address
City
State
ZIP Code
Phone Number
Email
Overpayment Information
Amount of Overpayment
Claim Year
Case/Claim Number
Hardship Statement
Describe your financial hardship and explain why you are requesting a waiver of the overpayment:
Income Information
Total Monthly Income
Household Size
Monthly Expenses
Rent/Mortgage
Utilities
Food
Transportation
Medical/Insurance
Other Expenses
Additional Information
Additional explanation or information (optional):
Signature
Date