Reemployment Assistance Appeals Commission Request For Review

Important:  This form is NOT intended for use in filing an appeal with a District Court of Appeal.
To file a court appeal, see Appealing a RAAC Order to a District Court of Appeal.

The Request for Review form below will require certain specific information in order to be properly filed with the Commission over the internet. If you do not have all of the required information but still intend to file a Request for Review of a referee's decision to the Commission, you will need to submit your Request for Review by fax or mail. You should provide the claimant's name and social security number on any Request for Review submitted to this Commission.

Required fields are indicated with *

* Appealing Party:  
* Person Submitting Form:  
* Referee Docket No. or Connect Issue ID:
9999999999-99
* Decision Date:
mm/dd/yyyy
* Last 4 Digits of Claimant SSN:
Last 4 digits of SSN
Claimant ID:
Appellant Email Address:
   

Claimant Information (* Required if Appealing Party is Claimant)
Name:  
Street Address:  
City:  
State/Territory:  Zip:  
Telephone Number:

Claimant Representative Information (if applicable)
Name:
Street Address:
City:
State/Territory:  Zip: 
Telephone Number:

Employer Information (* Required if Appealing Party is Employer)
Employer Number:  
Name:    
Contact Person:    
Street Address:    
City:    
State/Territory:  Zip:  
Telephone Number:

Employer Representative Information (if applicable)
Name:
Street Address:
City:
State/Territory:  Zip: 
Telephone Number:

(Parties requesting review by the Commission are requested to specify any and all allegations of error with respect to
the referee's decision, and to provide factual and/or legal support for the challenges.
Allegations of error not specifically set forth may be considered waived.)


I disagree with the Referee's decision for the following reason(s):    

If this appeal is not transmitted within 20 days of the decision date, please explain why:
   

 

IMPORTANT:   IN SUBMITTING THIS FORM, I HEREBY APPEAL THE REFEREE'S DECISION TO THE REEMPLOYMENT ASSISTANCE APPEALS COMMISSION.


* Name:
 
* Date:  (mm/dd/yyyy)

WARNING:  Department e-mail filters will reject all requests that contain profane and/or obscene language.




Reemployment Assistance Appeals Commission Request for Review - Rule 73B-21.002,
F.A.C. - DEO-A100RAAC(o)(4/12)