SD Eform - 0806 V2 -- Complete and use the button at the end to print for mailing
DLR-UID A-1 (3/15)

SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION
UNEMPLOYMENT INSURANCE APPEALS DIVISON
P.O. BOX 4730
ABERDEEN, SOUTH DAKOTA 57402-4730
TEL: 605.626.2310 FAX: 605.626.2322

APPEAL OF AND REQUEST FOR HEARING ON DETERMINATION
OR REQUEST FOR WAIVER OF OVERPAYMENT

MARK X ITEMS THAT APPLY TO THIS REQUEST.

I hereby appeal from a determination of the Benefit Section and request a hearing for the following reasons:
(State the specific part or parts of the determination to which you object and your reasons for objection.)

I hereby request a hearing for consideration of the right to waive the recovery of the overpayment. (State reasons why the right to recover the overpayment should be waived.) An overpayment may be waived, provided the overpayment was without fault of the claimant and where the claimant’s gross income for the preceding 12 months does not exceed a set standard. The claimant’s family income would include readily convertible assets of the claimant and his/her spouse.

Please sign and date form after printing it.