Request For Waiver Of Overpayment Of Unemployment Benets
Name: __________________________________Claimant ID or S.S.N.:_____________________ Date of Claim: ______________
In order to adjudicate your request for a waiver of debt under the provisions of the New Jersey Administrative Code, N.J.A.C. 12:17-14.2, please
respond to the following questions. Your answers will assist us in determining fault and whether or not it would be patently contrary to the
principles of equity and good conscience to require you to repay the overpayment on your claim. e Department of Labor and Workforce
Development is required to take into account all potential income of the claimant and the claimant’s family.
1. At any time before or since you received the benet payments that were determined to have been overpaid, did you:
a. Know that you provided information that was inaccurate? r Yes r No
b. Fail to provide information that was relevant to determining your eligibility? r Yes r No
c. Allow another individual(s) to fail to provide information that was relevant to determining your eligibility? r Yes r No
d. Know that you should not have been paid these benets? r Yes r No
2. How many dependants do you claim on your Federal Income Tax Return? ___________________________________
3. If married or in a civil union, what is your spouse’s/civil union partner’s social security number? __________________
4. Are you currently receiving any type of public/government assistance (food stamps, AFDC, etc.)?
r Yes $ ______________________ Amount per month r No
If “No,” have you applied for public/government assistance (food stamps, AFDC, etc.)? r Yes r No
5. State the reason(s) why you feel you should not have to repay this overpayment. _____________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I certify that the statements made on both sides of this form are true and accurate to the best of my knowledge. I understand
that the law provides penalties for making false statements. ese penalties include loss of benets, nes, refunds, prosecution
and imprisonment.
Claimant’s Signature: ____________________________________________Date: _______________________________
In order to complete the processing of your request, it may be necessary to verify any and all of your nancial data. Please
print or type your name in the space provided below and sign and date where indicated to allow release of personal nancial
data from banks, credit agencies or other nancial institutions and organizations to the New Jersey Department of Labor and
Workforce Development.
_____________________________________________ , do hereby authorize the release of all nancial records, credit
information, or any other data as required, to the New Jersey Department of Labor and Workforce Development.
Claimant’s Signature: ____________________________________________Date: _______________________________
Complete both sides of this form and mail it along with any supporting documentation to:
New Jersey Department of Labor and Workforce Development
Division of Unemployment Insurance
Bureau of Benet Payment Control
Refund Processing Section
PO Box 951
Trenton, NJ 08625-0951
BPC-9 (3-14) New Jersey Department of Labor and Workforce Develoment- Unemployment Insurance
Name: ____________________________ Claimant ID or S.S.N.: __________________Date of Claim: ____________
Claimant Spouse/Civil Union Partner
Last 12 Next 12 Last 12 Next 12
Months Months Months Months
Wages
Self-Employment
Unemployment
Pensions
Interest
Dividends
Social Security
Child Support/Alimony
Other Income
Total Income
Rent/Mortage
Property Taxes
Utilities
Food
Clothing
Medical
Auto Expenses/Gas
Auto Loan
Other Loans
Telephone
Cable/Satellite
Internet
Insurance
Child Support/
Alimony
Other
Total Expenses
Checking Account Balance: _______________________
Bank Name/ Address:
Savings Account Balance: _______________________
Bank Name/Address:
Investment/Brokerage Account Balance: _______________________
Institution Name/Address:
Cash on Hand: _______________________
Current Value of all Stocks: _______________________
Current Value of all Bonds: _______________________
Cash in Value of all Insurance Policies: _______________________
ASSETS (Claimant & Spouse/Civil Union Partner)
EXPENSES
Current Monthly
Balance Payment
INCOME
NOTE: If you have additional expenses or there are other factors that you wish to be considered, please attach
additional sheet(s). Please complete both sides of this form. Sign and date both sides and any attachments.
Claimant’s Signature______________________________________________Date:_____________________
