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APPEAL TO THE UNEMPLOYMENT INSURANCE APPEALS COMMISSION

UIAC Appeals Form

Please fill out the information below as completely as possible as it will help the Commission to timely process your appeal. Missing information may result in delay.

*Appealing Party Claimant Employer UIA

*Claimant

*Claimant Phone Number

*Claimant Street Address

*Claimant City

*Claimant State

*Claimant Zip Code

Employer(s)

Employer Address

Employer City

Employer State

Employer Zip Code

*MOAHR Docket Number

*Case No.

*Decision Date

If you would like to add more cases, click yes below.

Add More Yes

(If appealing multiple Administrative Law Judge Decisions and/or Orders, please list all Docket (Appeal) Nos, Case Nos, & Decision Dates) (attach additional pages/documents if necessary)

*Reason(s) for Appeal

Additional documents (PDF or Word)

*Date

*Filing Party Signature

*Filing Party Email Address

I agree that my electronic signature constitutes my signature and conveys my intent to sign this record.

Your appeal must be received at Unemployment Insurance Appeals Commission (Commission) within 30 days from the Mailed Date of the Administrative Law Judge’s (ALJ) Decision or Order. Questions – contact the Commission at 1-800-738-6372.

LEO is an equal opportunity employer/program.