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Service PROTECTED WHEN COMPLETED – B Canada

REQUEST FOR reconsideration of an Employment Insurance (EI) decisionFOR OFFICE USE ONLY Social Insurance NumberName of Claimant or Other PersonCanada Revenue Agency Business NumberName of Employer Name of Requestor:Mailing Address:City:Province:Postal Code:Telephone number (home):SC INS5210 (2015-07-008) EDate of Receipt of this Request for ReconsiderationPersonal information on this form is collected under the authority of the Employment Insurance Act. This information will be used to assess your request for a reconsideration of an Employment Insurance decision.

2. Please explain the reasons for the delay in filing your request for reconsideration: (Attach additional pages if required). SECTION 6: OTHER PERSON OR INTERESTED PARTY (To be completed only if you are not a claimant or an employer) Signature. Date1. Are you submitting this request for reconsideration on behalf of a claimant or an employer ...

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