NDOL | OPWaiverForm

Nebraska Good Life. Great Connections. Department of Labor

The CARES Act, the Continued Assistance Act, and the American Rescue Plan Act provide states the ability to waive recovery of Pandemic Unemployment Assistance (PUA), Pandemic Emergency Unemployment Compensation (PEUC), Federal Pandemic Unemployment Compensation (FPUC), Mixed Earner Unemployment Compensation (MEUC), and Lost Wages Assistance (LWA) overpayments in the event the overpayments were established through no fault of the claimant and the recovery of the overpayment would be against equity and good conscience.

Complete the form below if you wish to apply for a waiver of overpayment. Failure to provide the information requested in this application will result in the denial of your request to waive your overpayment. This form DOES NOT apply to regular state unemployment benefits. Applications are due within 30 days of the notice of overpayment. Pursuant to federal law, NDOL’s decision on the waiver is final and may not be appealed.

Waiver of Overpayment Application

Failure to provide the information requested in this application will result in the denial of your request to waive your overpayment.

Instructions on how to upload required documents requested below onto your NEworks account are located here.

Claimant Information

First name:

Last Name:

Overpayment Amount:

Last 4 Digits of SSN:

Address:

City:

State:

Zip Code:

Phone Number:

Cell Number:

Email Address:

Household Income

Number of persons in household:

Financial Statement

Monthly Gross Income: The following information is required. Please enter 0 if not applicable. You must upload to your NEworks account copies of your entire 2019 and 2020 federal income tax returns and/or Schedule C included for those claiming Self Employment.

Your current monthly gross income (before deductions):

Your spouse’s current monthly gross income (before deductions):

Other household members monthly net income (after deductions):

Social Security:

Pension and/or Retirement:

Severance:

Disability:

Unemployment Compensation:

Alimony:

Child Support:

TANF/Food Stamps:

Other Income (please list):

TOTAL INCOME:

Monthly Expenses

Monthly Expenses: The following information is required. Please enter 0 if not applicable. You must upload supporting documentation to your NEworks account for all monthly expenses listed below.

Mortgage(s)/Rent:

Home/Renters Insurance:

Water:

Gas:

Electric:

Cable:

Internet:

Telephone/Cellphone:

Transport (car payment, fuel, bus, etc):

Medical/Dental:

Food:

Child Care:

Student Loan(s):

Credit Card(s):

Auto Insurance:

Life Insurance:

Court ordered support paid out:

Other Expenses (please list):

TOTAL EXPENSES:

Personal Statement

Please explain why you believe that you were not at fault in causing the overpayment.*

Please explain why you believe that it would be unfair to require you to repay the overpayment.*

If required to repay the overpayment, how much can you pay per month?

Affirmation

I hereby request a waiver of my overpayment. I understand that in order to be considered for a waiver of my overpayment, I must complete the Overpayment Waiver application within 30 days of the notice of overpayment. Pursuant to federal law, NDOL’s decision on the waiver is final and may not be appealed. I also understand that failure to provide the information requested in this application will result in the denial of this request to waive my overpayment.

I AFFIRM THAT THE INCOME, EXPENSES, AND INFORMATION LISTED ON THIS FORM ARE CORRECT.

Signature:

Sign Date:

9/20/2024