Benefits Decision Non-Receipt Form
Report the non-receipt of your benefits decision notice. Please complete all relevant fields so we can assist you promptly.
Claimant Full Name
*
First Name
Last Name
Preferred Contact Method
*
Email
Phone
Mail
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Benefits Program Type
*
Please Select
Unemployment Benefits
Disability Benefits
Retirement Benefits
Health Assistance
Other
Decision or Notice Type
*
Please Select
Approval Notice
Denial Notice
Request for Information
Payment Statement
Other
Date Decision Was Expected or Last Checked
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Did you experience any issues with mail, email, or online account access?
*
No issues
Mail delivery issue
Email delivery issue
Online account access issue
Briefly describe the non-receipt issue
*
Preferred way to receive the missing notice
*
Email
Mail
Online account notification
Additional notes or attach supporting documents (optional)
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