Request for Waiver

The U.S. Department of Labor has given state agencies the authority to waive repayments of overpaid unemployment insurance benefits under certain conditions during the pandemic. You may not have to pay back the overpaid benefits if you received unemployment benefits from one of the federal pandemic emergency benefit programs and it is determined that the payment of these benefits was not your fault and repayment would be an unreasonable hardship for you.

This means that you can request a waiver if the Employment Department paid you for Pandemic Emergency Unemployment Compensation (PEUC), Federal Pandemic Unemployment Compensation (FPUC), Pandemic Unemployment Assistance (PUA), or Lost Wages Assistance (LWA) benefits and later found that you were actually not eligible for those benefits (also known as an “overpayment”). After you submit the waiver, we will decide if federal law allows you to not repay the overpayment (also known as “waiving repayment”).

Examples of reasons you could be eligible to have your overpayment waived include:
1. The Employment Department made a mistake in processing your claim.
2. The Employment Department put benefits on an incorrect claim.
3. You did not cause the overpayment and repayment would mean you or your household has to go without basic necessities.
4. You did not cause the overpayment and you have a health issue or disability that would make repayment a hardship.

First Name*

Last Name*

Social Security Number (SSN)*

Phone Number*

Are you now employed?*

How would repaying this overpayment create a hardship for you or your household?*

Did receiving these benefits cause you to do something you would not have done if you had not received the benefits? If so, how?*

Did your position change for the worse because you received these benefits? If so, how?*

Do you have a health issue or disability that would make repayment a hardship?*

Do you have the money to repay this overpayment?*

If you have to repay the overpayment, what necessities would you or your household have to go without (check all that apply)?*

If other, what necessities would you or your household go without?

Additional information about you or your household that you would like us to consider when deciding whether you are eligible to waive repayment of an overpayment. Please note that your reasons must include how you were not at fault and how having to repay the overpayment would be contrary to equity and good conscience (see reasons listed above).

It may take 2‐3 weeks from the date we receive your request until a decision is mailed to you. Do not submit multiple requests or inquire on that status of your request unless four weeks have passed and you still haven’t received a decision. We will reach out to you if we need additional information. There will be information included in your decision that will let you know what to do if you don’t agree with the decision we issued.

If you need help completing this form, please call 503.947.1995.

The above information is furnished voluntarily and I hereby apply for waiver of repayment established by the State of Oregon. I certify the information provided is true and correct to the best of my knowledge:*