JOHN DOE 123 ANYPLACE AVENUE CITY PLACE, UNION STATE 07202 Telephone: 123-456-7890 Myemail@yahoo.

com Required Response From: Division of Unemployment Insurance Customer Service Office Fax: (609) 292-2438 Petitioner: Claimant: JOHN DOE Date of Original Claim 12/16/2012 SS ID: 123-45-6789 Dependent Spouse: JANE DOE (xxx-xx-1234) Originally Sent: July 12, 2013 & August 8, 2013 address and phone number NOTE :This a re-fax to update

FOR NOTICE OF: ADMINISTRATIVE APPEAL for Unreceived Unemployment Dependency Benefits (THIRD ATTEMPT.) STATEMENT OF FACTS 1. Petitioner applied for UI benefits on 12.16.12. 2. Petitioner submitted an application for dependency benefits and included a marriage certificate in support of addition of spouse as dependent. 3. The 2011 tax year is from January 1, 2011 December 2011. 4. The Petitioners date of marriage was March 1, 2012. 5. Petitioner received his original application, which was returned by NJDOLUI division with a request for a copy of 2011 tax return some time in April 2013. 6. Petitioner ordered a copy of his 2011 tax return from the IRS. 7. Petitioner complied with request and returned the original dependency benefits application along with 2011 tax year return sometime in April 2013. 8. UPS Tracking confirmed receipt of Petitioners dependency benefits application and 2011 tax return by NJDOL UI division. 9. Petitioner has received no additional notices of deficiency or requests for additional information from NJDOL UI division. 10. Petitioner called in the UI hotline to check on the status of dependency benefits claim processing and was informed that the dependency benefit claim was denied, although the application (a) was returned for additional information (b) the request was complied with (c) the requested information

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was received by NJDOL UI division and (d) there was no formal notice to the Petitioner of denial. The UI claims agent informed petitioner that the Petitioner should submit an appeal in regards the denial of dependency benefits. Petitioner has not received a formal notification of denial and it has been over 90 days since receipt and acceptance of Petitioners certified mailing of UI dependency documents. Petitioner faxed initial appeal request on 7/12/13 to NJDOL UI division and fax confirmation was confirmed by fax receipt. Petitioner refaxed appeal on 8/08/13 with updated address and phone number and receipt by NJDOL UI division was confirmed by fax receipt. After speaking with NJDOL UI Agent Coco Beware, Petitioner was informed that NJDOL UI had no record of either the initial or second appeal petition, (see line items 13 and 14) Petitioner was instructed to once again send petition, this time via as well as fax.

PRAYER OF REMEDY SOUGHT: The Petitioner seeks the remedy of the payment of UI dependency benefits for the spouse which was stated on Petitioners dependency benefits application, calculated from the date of the original claim to present and onward, which is stated to be 7% addition to the base amount per week and per dependent. Petitioner also requests that the 7% also be applied at a commensurate rate for the weeks prior to the federal benefits reduction. The Petitioner has complied in good faith with the stated requirements for dependency benefits eligibility and has seen no reason why this request for remedy should not be granted. The clamant sincerely appreciates the diligence and due care which the New Jersey Department of Labor Unemployment Division will take in redressing this issue. If any additional information is required the Petitioner may be contacted at the following number: Best Regards, /s/ JOHN DOE