The Tribunal has specifically created this form to allow you to appeal the Notice of Adjudicator's Determination without having to appeal on-line through the Nebraska Department of Labor's BPS site. This notice must be returned to the Tribunal within 20 days of the date that the Notice of Adjudicator's Determination was mailed to you. Failure to return this notice on time will result in your appeal being dismissed.

If you have already filed for an appeal, filing a second appeal is not necessary. Only complete and return this appeal form if you have not yet filed an appeal.

This form may be completed online, and answers may be inserted in the areas provided. The form cannot be saved with the information entered. To save the information, the form must be printed and either faxed or mailed to the Tribunal. Please remember to SIGN and DATE the form prior to returning it to the Tribunal.

QUESTION #1: Provide your name, street address (or PO Box), city, state, ZIP code and telephone number (with area code) in the space provided. Fax number and e-mail address can be included, but are not required.

QUESTION #2: Provide your social security number.

QUESTION #3: Briefly state the reason that you are appealing in the space provided.

QUESTION #4: Provide the name and title of the attorney or hearing representative representing the claimant along with the attorney or hearing representative's business, street address (or PO Box) and business telephone number (with area code) in the space provided. IF YOU DO NOT HAVE AN ATTORNEY OR YOUR ATTORNEY HAS NOT AGREED TO APPEAR WITH YOU IN THIS HEARING, PLEASE LEAVE THIS AREA BLANK.

SIGNATURE LINE: Please remember to SIGN and DATE this request before sending it to the Nebraska Center. If you fail to sign and date this form, your request will then be denied.

Do not write in the space below the signature line that says CLAIMS CENTER ONLY.

Please return the NOTICE OF APPEAL to the Nebraska Appeal Tribunal, P.O. Box 98941, Lincoln, NE 68509-8491. This form may also be faxed to the Tribunal at (402) 471-1734.

You may use this form only if you did not receive a Telephone Information Return Form with your Notice of Telephone Hearing form or lost the original form sent to you in the mail. You may type in the answers in the spaces provided.

This form allows you to notify the Tribunal of your contact telephone number, your witnesses (if any) and their telephone numbers along with the certificate of service.

You may type your answers in the spaces provided. Once complete, you may print this form. Please remember to SIGN and DATE this request before sending it to the Nebraska Appeal Tribunal. You may also print the form and fill in the answers either by hand or by typing the answers neatly in the space provided.

Although the form allows you to print your answers in the gray areas provided, it will not save the information on the form once you exit the program. To ensure that your information is saved, you should make sure all information is correct before exiting the form.

Docket No. (found at the upper right-portion of the form): “Docket No.” stands for the docket number of your case. If you do not know your docket number, you can find it in the upper right-hand corner of the NOTICE OF APPEAL FILED or the NOTICE OF TELEPHONE HEARING. If you cannot find your docket number, make sure and list your social security number in the space marked under Claimant Information. The Tribunal will need you to put either the docket number or your social security number (or both) so it can quickly find your case.
QUESTION 1, CLAIMANT'S INFORMATION: Please provide YOUR name, your current address, and include apartment number, lot number, etc., and the city, state, and zip or postal code of where you live. Please also provide your social security number. You should try to indicated the date and time of your hearing (you can find it listed the NOTICE OF TELEPHONE HEARING).

You will need to list the telephone number that you will be for the hearing. If you need an interpreter, please mark the correct box.

QUESTION 2, WITNESSES: Please list the full name (first AND last name) and the telephone numbers (with area code) of any witnesses in the spaces provided. You will also need to tell the Tribunal if these witnesses need an interpreter and what language they speak. Witnesses should know that they are to appear for the hearing. You must make sure that witnesses have agreed to participate in the hearing with you before you submit their names and numbers to the Tribunal.

QUESTION 3, ATTORNEY: If you have an attorney that is planning to appear with you at the hearing, please provide his or her name, firm or business name, mailing address, and telephone number (both contact number and the number where they will be available for the hearing) in the space provided. If your attorney is not going to appear or you do not have an attorney, PLEASE LEAVE THIS SPACE BLANK.

QUESTION 4, DOCUMENTS: If you have any documents that you wish to submit to the Tribunal as evidence to support your case, you may then return them with this form. Please list the number of pages of documents that you wish to send to the Tribunal in the space provided. If you have no documents to send, simply enter “0” or leave space blank.
QUESTION 5, CERTIFICATE OF SERVICE: You only need to complete question no. 5 if you submitted documents to the Tribunal. If you submitted documents, you will need to send copies to the Employer or any other party (such as the Department of Labor). By completing the Certificate of Service shows that you sent the Employer your documents before the hearing. If you did not submit any documents to the Tribunal, you can leave this space blank.

SIGNATURE LINE: Please remember to SIGN and DATE this form before sending it to the Nebraska Appeal Tribunal.

Do not write in the space below the signature line that says CLAIMS CENTER ONLY.

Please return the NOTICE OF APPEAL to the Nebraska Appeal Tribunal, P.O. Box 98941, Lincoln, NE 68509-8491. This form may also be faxed to the Tribunal at (402) 471-1734.
 

On this form, you can request your hearing date be continued. Continuances must be requested at least FIVE DAYS before the hearing. Should you have a special circumstance, such as a family emergency, the Tribunal may consider continuance requests up to the time of hearing. 

An Administrative Law Judge will review your request and rule on whether or not the continuance will be granted or denied. As with all other matters, the Tribunal Staff may not give legal advice. The Tribunal staff will not provide reasons or explanation for an Administrative Law Judge's decision on granting or denying a continuance request.

When filling out this form, type or print answers neatly in the area provided. Make sure you list the DOCKET NUMBER of you case in the space required. If you do not know your docket number, you can find it in the upper right-hand corner of the NOTICE OF APPEAL FILED or the NOTICE OF TELEPHONE HEARING. If you do not provide the information required, your request for continuance will be denied.

QUESTION #1: Provide your name, street address (or PO Box) and telephone number (with area code) in the space provided. 

QUESTION #2: Provide the specific reason for your request. Please state whether or not you will be available by telephone at the time of hearing. If your request for a continuance is because a witness is unavailable, please answer QUESTION #3.

QUESTION #3: If there are no other witnesses available, please answer “no." If there are other witnesses that can provide the same testimony, please answer “yes” and provide the names of witnesses that can provide the same testimony as the person that is unavailable for the hearing.

QUESTION #4: For this question, you should tell the Tribunal the alternate dates and times that you or your witness(es) would be available for the hearing. When suggesting alternative dates, please remember that the Tribunal is only open Monday through Friday, excluding legal holidays as recognized by the state of Nebraska. Hearings will only be scheduled between the hours of 8:30 a.m. to 3:30 p.m. Central Time. No exceptions will be granted.

SIGNATURE LINE: Please remember to SIGN and DATE this request before sending it to the Nebraska Appeal Tribunal. If you fail to sign and date this form, your request will be denied. 

Do not write in the space below the signature line that says FOR TRIBUNAL USE ONLY.

Please return the CLAIMANT'S REQUEST FOR CONTINUANCE form to the Nebraska Appeal Tribunal, P.O. Box 98941, Lincoln, NE 68509-8491. You may also fax this to the Tribunal at (402) 471-1734.

On this form, you can request that the Tribunal issue a subpoena for a witness to testify at your hearing. To have a subpoena issued, you must make your request at least FIVE DAYS before the hearing. An Administrative Law Judge will review your request and rule on whether or not the subpoena will be granted. An Administrative Law Judge may deny the subpoena based on whether or not a witness can provide relevant testimony or testimony that is material to the case. The Tribunal may also deny a subpoena should you request an excessive number of witnesses in a case. As with all other matters, the Tribunal Staff may not give legal advice. The Tribunal staff will not provide reasons or explanations for an Administrative Law Judge's decision on granting or denying a subpoena.

When filling out this form, type or print answers neatly in the area provided. Make sure you list the DOCKET NUMBER of your case on all subpoenas. If you do not know your docket number, you can find it in the upper right-hand corner of the NOTICE OF APPEAL FILED or the NOTICE OF TELEPHONE HEARING. If you do not provide the information required, your subpoena will be denied.

QUESTION #1: Provide your name, street address (or PO Box) and telephone number (with area code) in the space provided. 

QUESTION #2: Provide the name of a witness that you wish to subpoena. If you do not know the first and last name of the person you wish to have as a witness, then the Judge will not grant your subpoena. If you are requesting subpoenas for more than one witness, you will need to file a separate subpoena for each additional witness.

QUESTION #3: Please answer yes or no if you have asked this witness to testify without a subpoena. If you answered question #3 with “no,” you should provide a good reason why you have not asked them to testify in the space provided.

QUESTION #4: If you answered “Yes” to this question, please state if this testimony can be provided by yourself or another witness that is already planning to attend the hearing. Please state the name or names of witnesses who have agreed to participate and can provide the same testimony as the person you wish to subpoena.

QUESTION #5: Briefly state the testimony this witness will provide that is relevant to your case. 

QUESTION #6: In this space, provide the witness's name and the address where the Tribunal can send the subpoena.

SIGNATURE LINE: Please remember to SIGN and DATE this subpoena before sending it to the Nebraska Appeal Tribunal. If you fail to sign and date this subpoena, your request will then be denied. 

Do not write in the space below the signature line that says FOR TRIBUNAL USE ONLY.

Please return the CLAIMANT'S REQUEST FOR WITNESS SUBPOENA form to the Nebraska Appeal Tribunal, P.O. Box 98941, Lincoln, NE 68509-8491. You may also fax this to the Tribunal at (402) 471-1734.

On this form, you can request that the Tribunal issue a subpoena for documents to be provided to you. To have a subpoena issued, you must make your request at least FIVE DAYS before the hearing. An Administrative Law Judge will review your request and rule on whether or not the subpoena will be granted. An Administrative Law Judge may deny the subpoena based on whether or not a document can provide relevant information or information that is material to the case. The Tribunal may also deny a subpoena should you request an excessive number of documents in a case. As with all other matters, the Tribunal Staff may not give legal advice. The Tribunal staff will not provide reasons or explanations for an Administrative Law Judge's decision on granting or denying a subpoena. All other communications to the Tribunal challenging a Judge's decision will be disregarded.

When filling out this form, type or print answers neatly in the area provided. Make sure you list the DOCKET NUMBER and your name on all subpoenas. If you do not know your docket number, you can find it in the upper right-hand corner of the NOTICE OF APPEAL FILED or the NOTICE OF TELEPHONE HEARING. If you do not provide the information requested, your subpoena will be denied.

QUESTION #1: Provide your name, street address (or PO Box) and telephone number in the space provided. 

QUESTION #2: Identify the documents that you wish to subpoena. List the name of the document and approximate number of pages in the document. If you are not specific concerning the document that you wish to subpoena, then the Judge will not grant your subpoena.

QUESTION #3: Please answer yes or no if you have asked for these documents from the person or company that has them. If you answered “no” please state the reason why you have not asked for specific documents in the space provided.

QUESTION #4: Briefly state the reason why each document is relevant to your case. If you feel you need more space for your response, you may then attach the additional information to your request.

QUESTION #5: Please answer yes or no if these documents can be provided by yourself or by another source. If you answered yes, please state the name or names of documents that can provide the same information as the document or documents you wish to subpoena.

QUESTION #6: In this space, provide the name and the address where the Tribunal can send the subpoena.

SIGNATURE LINE: Please remember to SIGN and DATE this subpoena before sending it to the Nebraska Appeal Tribunal. If you fail to sign and date this subpoena, your request will then be denied. Do not write in the space below the signature line that says FOR TRIBUNAL USE ONLY.

Please return the DOCUMENT SUBPOENA FORM to: Nebraska Appeal Tribunal, P.O. Box 98941, Lincoln, NE 68509-8491. You may also fax this to the Tribunal at: (402) 471-1734.

On this form, you can request that the Tribunal reconsider its decision to deny you benefits in your case. You can also use this form if the Tribunal dismissed your appeal because you did not appear at the hearing. Reconsideration requests are rarely granted but may be considered if a mistake of law has been made, there is newly discovered evidence that could not have been presented at the time of the hearing through due diligence, or if a party did not receive notice of the hearing and did not appear. Responses must be returned to the Tribunal within 10 days of the date that the order was mailed to you. If you fail to return this response on time, your appeal will be dismissed.

An Administrative Law Judge will review your response and rule on whether or not you have provided the Tribunal with sufficient reasons to reopen or reconsider you appeal. As with all other matters, the Tribunal Staff may not give legal advice. The Tribunal staff will not provide reasons or explanations for an Administrative Law Judge's decision.

This form allows you to type your answers in the spaces provided. Once complete, you may print this form. Please remember to SIGN and DATE this request before sending it to the Nebraska Appeal Tribunal. You may also print the form and fill in the answers by either printing or typing the answers neatly in the space provided.

Although the form allows you to print your answers in the gray areas provided, it will not save the information on the form once you exit the program. To ensure that your information is saved, you should make sure all information is correct before exiting the form. You should also list the DOCKET NUMBER of you case in the space required. If you do not know your docket number, you can find it in the upper right-hand corner of the NOTICE OF APPEAL FILED or the NOTICE OF TELEPHONE HEARING. If you do not provide the information required, your request for reconsideration will be denied.

QUESTION #1: Provide your name, street address (or PO Box) and telephone number (with area code) in the space provided. 

QUESTION #2: Briefly state the reason why you believe the Tribunal should reconsider its decision to deny you benefits or dismissing you appeal in the space provided.

SIGNATURE LINE: Please remember to SIGN and DATE this request before sending it to the Nebraska Appeal Tribunal. If you fail to sign and date this form, your request will then be denied.

Do not write in the space below the signature line that says FOR TRIBUNAL USE ONLY.

Please return the CLAIMANT'S REQUEST TO RECONSIDER DECISION to the Nebraska Appeal Tribunal, P.O. Box 94600, Lincoln, NE 68509. You may also fax this to the Tribunal at (402) 471-1734.

This form is for claimants who are deaf or hard of hearing. The Tribunal can accommodate either individuals who would prefer to have a hearing by text device or an in-person hearing. You should realize that in-person hearings do take more time to arrange. To insure that a place and date are available, you should complete this form as soon as possible.

An Administrative Law Judge will review your response and rule on the decision. Most requests are granted as long as they are not unreasonable. As with all other matters, the Tribunal Staff may not give legal advice. The Tribunal staff will not provide reasons or explanation for an Administrative Law Judge's decision.

When filling out this form, type or print answers neatly in the area provided. Make sure you list the DOCKET NUMBER of you case in the space required. If you do not know your docket number, you can find it in the upper right-hand corner of the NOTICE OF APPEAL FILED or the NOTICE OF TELEPHONE HEARING. If you do not provide the information required, your response will be ignored.

QUESTION #1: Provide your name, street address (or PO Box) and telephone number (with area code) in the space provided. 

QUESTION #2: Mark the box stating the type of interpreter you would prefer. If you are requesting an in-person hearing, please indicate a location for the hearing. 

QUESTION #3: For this question, you should tell the Tribunal the dates and times that you or your witness(es) would be available for the hearing. When suggesting dates, please remember that the Tribunal is only open Monday through Friday, excluding legal holidays as recognized by the state of Nebraska. Hearings will only be scheduled between the hours of 8:30 a.m. to 3:30 p.m. Central Time. No exceptions will be granted.

SIGNATURE LINE: Please remember to SIGN and DATE this request before sending it to the Nebraska Appeal Tribunal. If you fail to sign and date this form, your request will then be denied. 

Do not write in the space below the signature line that says FOR TRIBUNAL USE ONLY.

Please return the CLAIMANT'S REQUEST FOR INTERPRETER (DEAF OR HARD OF HEARING) to the Nebraska Appeal Tribunal, P.O. Box 98941, Lincoln, NE 68509-8491. You may also fax this to the Tribunal at (402) 471-1734.

This form is to allow parties to respond to an Order for More Definite Statement. An Administrative Law Judge will review and rule on your response. If a proper response is provided, the matter will be set for hearing. If the response is not made timely or is insufficient, the appeal will be dismissed. As with all other matters, the Tribunal Staff may not give legal advice. The Tribunal staff will not provide reasons or explanation for an Administrative Law Judge's decision. 

This form will need to be printed and information filled by typing or printing answers neatly in the area provided. Make sure you list the DOCKET NUMBER of your case in the space required. If you do not know your docket number, you can find it in the upper right-hand corner of the NOTICE OF APPEAL FILED or the NOTICE OF TELEPHONE HEARING. If you do not provide the information required, your response will be ignored. 

QUESTION #1: Provide your name, street address (or PO Box), telephone number (with area code), and fax or e-mail address in the space provided. 

QUESTION #2: Mark the box whether you are the employer, or claimant. 

QUESTION #3: For this question, you should tell the Tribunal why you are appealing such as "I quit because of health reasons" or "I was fired for showing up late." If you want to give a more detailed reason for the appeal, you may attach a longer statement to this form.

SIGNATURE LINE: Please remember to SIGN and DATE this request before sending it to the Nebraska Appeal Tribunal. If the employer fails to sign and date this form, the request will then be denied. 

Do not write in the space below the signature line that says FOR TRIBUNAL USE ONLY.

Please return the CLAIMANT'S REQUEST FOR INTERPRETER (HEARING IMPAIRED) to the Nebraska Appeal Tribunal, P.O. Box 98941, Lincoln, NE 68509-8491. You may also fax this to the Tribunal at (402) 471-1734.