STATE OF MAINE
STATE OF MAINE
UNEMPLOYMENT INSURANCE COMMISSION
57 State House Station
Augusta, ME
04333-0057
REQUEST FOR COMMISSION HEARING ON
STATE INCOME TAX REFUND SETOFF
|A copy of the Disposition of Tax Refund Notice, issued by Maine Revenue Services, MUST accompany this form/request. |
|Debtor’s Name (Last) (First) (Middle Initial) |Date of Request |
|Mailing Address (No., Street, or RFD) |Social Security Number of the |
| |Claimant-Proprietor-Partner |
| | |
|City State Zip |Employer’s State Identification Number |
| | |
|Telephone Number |Claim Center Name |
|Appealed By: |
|[ ] Claimant [ ] Proprietorship/Partnership [ ] Corporation |
Provisions of 36 M.R.S. Section 5276-A.2 require that the hearing be limited to the issues of whether the debt became liquidated and whether any post-liquidation events have affected the liability.
Claimant:
I request a hearing on the intended setoff of my State Income Tax Refund, all or part of which is to be credited to the overpayment established on my benefit account, including interest and penalties.
Reason for Hearing: _____________________________________________________________
Employer:
I request a hearing on the intended setoff of State Income Tax Refund, all or part of which is to be credited to contributions, interest, or penalties due the Maine Department of Labor.
Reason for Hearing: _____________________________________________________________
|Debtor’s Signature |
| |
Received on By
Agency Representative
|Questions About This Form? |
|Contact the Unemployment Insurance Commission at (207) 623-6786, Fax: (207) 287-4554, |
|TTY Users Call Maine Relay 711 |
-----------------------
JENNIFER J. DUDDY, ESQ.
CHAIRMAN
JEAN A. ROY
LABOR REPRESENTATIVE
JOSEPH J. KLAUS
EMPLOYER REPRESENTATIVE
JANET T. MILLS
GOVERNOR
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