On-line Appeal to Unemployment Insurance Determination - Entry Form

To file an appeal electronically, please complete this form and follow the filing instructions below. Fields marked with an asterisk (*) are mandatory and must be completed.

I hereby appeal the DETERMINATION in the following Unemployment Insurance matter:

Required Field = SSNEmployee SSN:
   
Enter the Social Security Number of the employee listed on the DETERMINATION e.g., (123456789).
Required Field = Employee NameEmployee Name:
 
Enter the complete name of the employee as shown on the DETERMINATION.
Employer Account Number:  Suffix:
   
Enter the 6 digit UI Account number and, if applicable, the suffix (e.g., AA) of the employer as shown on the DETERMINATION (if no employer is shown on the DETERMINATION, this box may be left blank).
Employer Name:
Enter the complete name of the employer as shown on the DETERMINATION (if no employer is shown on the DETERMINATION, this box may be left blank).
Address1:

Address2:
 
City, State and Zip
Enter the address at which work was performed, if different from the employer's address on the DETERMINATION.

Required Field = ID NumberID Number:
   
Enter the 9-digit ID number shown in the upper left-hand corner of the DETERMINATION.
Required Field = Determination DateDetermination Date:
    
Enter the date (mmddyyyy) shown in the DATE MAILED box at the bottom of the DETERMINATION.
Required Field = Determination DateAppeal Reason:       
You must explain why you disagree with the determination.



Late Appeal Reason:        
If this appeal is late, please explain why the appeal is late.


Attorney/Agent Name:

Address1:

Address2:
   
City, State, & Zip:

Telephone:
   
If you will be represented by an attorney/agent, please provide the name, address, and telephone number of the attorney/agent. 








Dates / Times Not Available for Hearing: Enter any dates and/or times when you, your attorney/agent, or your witness(es) cannot attend a hearing within the next 30 days.
Interpreter Language:
If you need TTY or an interpreter, please select TTY or language.
Special Needs:
Indicate any special needs or other accommodations needed due to disability (e.g., Other language interpreter).


  Information about the person filing the Appeal:
Required Field = Appeal Filer NameYour Name:
 
The person filing this appeal must enter his or her name here.
Required Field = Appeal Filer AddressRole:
 
The person filing this appeal must indicate whether they are the employee, the employer, the employee's attorney/agent or the employer's attorney/agent.
Required Field = Appeal Filer AddressAddress1:
 
Address2:
 
                                   
Required Field = Appeal Filer NameCity, State and Zip:
   
The person filing this appeal must enter his or her mailing address here.



Telephone:
 
The person filing this appeal should enter his or her telephone number here.


Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)].


Wisconsin.gov | Site Map | Search | Accessibility | Legal | Feedback | DWD Home