PUA Overpayment Waiver Request

1 STATE OF MARYLANDDEPARTMENT OF LABORDIVISION OF UNEMPLOYMENT INSURANCEREQUEST FOR Waiver OF RECOUPMENT OF Overpayment OFFEDERAL PANDEMIC UNEMPLOYMENT INSURANCE BENEFITSThis Request for a Waiver of Overpayment Recovery ( Waiver ) of Pandemic Unemployment Assistance ( PUA ) andPandemic Unemployment Emergency Compensation ( PEUC ), federal pandemic unemployment compensation (FPUC),and/or Mixed Earner Unemployment Compensation (MEUC) benefits (collectively federal pandemic benefits ) must bemade within thirty (30) days from the date of the original Overpayment notice or the date on which the MarylandDepartment of Labor notified you of your right to Request a Waiver , whichever is later. You can show good cause forfailure to meet the 30-day Maryland Department of Labor has a separate Overpayment Waiver Request form for other unemployment insurance programs, including regular unemployment insurance, Unemployment Compensation for Ex-servicemembers ( UCX ), Unemployment Compensation for Federal Employees ( UCFE ), Work Sharing, and Extended assessing Waiver requests for federal pandemic benefits overpayments , the Maryland Department of Labor mustdetermine that: (1) the Overpayment was not the claimant s fault, and (2) repayment would be contrary to equity and assessing the second requirement regarding equity and good conscience, the Maryland Department ofLabor must consider the following factors.

2 (a) it would cause the claimant financial hardship, (b) recovery couldbe unconscionable under the circumstances, or (c) the claimant can show (regardless of their financialcircumstances) that due to the notice that such federal pandemic benefits payment would be made or because ofthe incorrect federal pandemic benefits payment, either they have relinquished a valuable right or changedpositions for the respect to the first factor, the Maryland Department of Labor looks at the claimant s ability to pay now andin the foreseeable future or whether they are a part of a household that is below the federal minimum povertylevel and likely to remain there for the foreseeable future. The following is a chart of the current Department ofHousing and Human Services poverty guidelines:Current HHS Poverty GuidelinesPersons in Family48 ContiguousStates and $12, $15, $14, $16, $21, $19, $21, $26, $24, $25, $32, $29, $30, $37, $34, $34, $43, $39, $39, $48, $44, $43, $54, $49, each additionalperson above 8, add:$4, $5, $5, you meet the above criteria, please complete the following to Request a Waiver of your federal pandemic AddressCity, State, ZipTelephoneNumberEmail AddressAFFIDAVIT OF CURRENT INCOME AND LIVING EXPENSESA verage Monthly Household Current monthly gross income:Please provide copies of your two (2) most recentpay highest level of education or vocational spouse s current monthly gross income:Please provide copies of your spouse s two (2) mostrecent pay Name.

3 Spouse Social Security names, ages, and Social Security Numbers forall dependents residing in your home (attach additionalpagesas necessary):Name:Age:SSN:Monthly Gross Income:Name:Age:SSN:Monthly Gross Income:Name:Age:SSN:Monthly Gross Income:Name:Age:SSN:Monthly Gross Income: Waiver RequestIn order for the Request for Waiver to be approved,you must show that (a) it would cause you financialhardship, (b)recovery would be unconscionable under the circumstances,or (c) because you expected a federal pandemic benefitspayment or received an incorrect federal pandemicbenefits payment, you gave up a valuable right orchanged positionsfor the worse (in other words, you relied on the federalpandemic benefits payment when making a decision).Please usethe space provided below or an attached sheet to indicatewhat conditions exist that qualify you for a waiverof yourfederal pandemic benefits Overpayment .

4 If the reasonis due to medical complications, please enclose amedical StatementOther monthly gross income-Please list all incomefrom each of the below categories and provide prooffor each:Social SecurityPension and/or RetirementSeveranceDisabilityUnemploymen t CompensationAlimonyChild SupportTANF/Food StampsOther Income (please list)TOTAL INCOME ANDASSETSM onthly Expenses Please list your monthly expenses below and provide supporting documentation ( , copies ofbills or rental agreements) for each:Mortgage/RentSecond MortgageWaterGasElectricCableInternetMed ical/DentalTelephoneTransportation (CarPayment, fuel, bus,etc.)FoodChild CareStudent Loan(s)Credit Card(s)Home/Renter s InsuranceAuto InsuranceHealth InsuranceLife InsuranceCourt ordered supportpaid outOther (please specify)TOTAL on a separate of Bank/Financial Institution:Bank/Financial Institution Address:Type of Account:CheckingSavingsCertificate ofDepositsOther:Account Number:Value of Account:Name of Bank/Financial Institution:Bank/Financial Institution Address:Type of Account:CheckingSavingsCertificate ofDepositsOther:Account Number:Value of Account:Name of Bank/Financial Institution:Bank/Financial Institution Address:Type of Account:CheckingSavingsCertificate ofDepositsOther:Account Number:Value of Account:Name of Bank/Financial Institution:Bank/Financial Institution Address:Type of Account:CheckingSavingsCertificate ofDepositsOther:Account Number:Value of Account.

5 CERTIFICATION AND SIGNATUREI understand that failure to answer the questionson this form truthfully may be considered unemploymentinsurance fraud. Ihereby certify that my answers to the questions onthis form are true and AFFIRM, UNDER THE PENALTIES OF PERJURY, THAT THEINCOME, EXPENSES, AND INFORMATIONLISTED ON THIS FORM ARE ACCURATE AND s Signature:Date:When you have completed this form, please mail itand all attachments you wish to present to the followingaddress:Maryland Department of LaborATTN: Benefit Payment Control1100 North Eutaw Street, Room 206 Baltimore, MD 21201(410) 767-2404 MAIL COMPLETED FORM TO THE ABOVE ADDRESS WITHIN 30 DAYSFROM THE DATE OF THE ORIGINAL Overpayment NOTICE ORTHEDATE ON WHICH THE DEPARTMENT NOTIFIED YOU OF YOURRIGHTTO Request A Waiver , WHICHEVER IS LATER.