PUA Overpayment Waiver Request
PUA Overpayment Waiver Request
DEPARTMENT OF LABOR
DIVISION OF UNEMPLOYMENT INSURANCE
This Request for a Waiver of Overpayment Recovery (“Waiver”) of Pandemic Unemployment Assistance (“PUA”) and
Pandemic Unemployment Emergency Compensation (“PEUC”), federal pandemic unemployment compensation (FPUC),
and/or Mixed Earner Unemployment Compensation (MEUC) benefits (collectively “federal pandemic benefits”) must be
made within thirty (30) days from the date of the original overpayment notice or the date on which the Maryland
Department of Labor notified you of your right to request a Waiver, whichever is later. You can show good cause for
failure to meet the 30-day requirement.
The Maryland Department of Labor has a separate overpayment Waiver request form for other unemployment
insurance programs, including regular unemployment insurance, Unemployment Compensation for
Ex-servicemembers (“UCX”), Unemployment Compensation for Federal Employees (“UCFE”), Work Sharing,
and Extended Benefits.
In assessing Waiver requests for federal pandemic benefits overpayments, the Maryland Department of Labor must
determine that: (1) the overpayment was not the claimant’s fault, and (2) repayment would be contrary to equity and good
conscience.
When assessing the second requirement regarding equity and good conscience, the Maryland Department of
Labor must consider the following factors: (a) it would cause the claimant financial hardship, (b) recovery could
be unconscionable under the circumstances, or (c) the claimant can show (regardless of their financial
circumstances) that due to the notice that such federal pandemic benefits payment would be made or because of
the incorrect federal pandemic benefits payment, either they have relinquished a valuable right or changed
positions for the worse.
With respect to the first factor, the Maryland Department of Labor looks at the claimant’s ability to pay now and
in the foreseeable future or whether they are a part of a household that is below the federal minimum poverty
level and likely to remain there for the foreseeable future. The following is a chart of the current Department of
Housing and Human Services poverty guidelines:
Claimant’s
Name Xavier Pender
S.S. No. 117-82-0552
Street Address 3519 Madison Pl.
City, State, Zip Hyattsville, MD 20782
Telephone
Number 240.623.0718
Email Address [email protected]
AFFIDAVIT OF CURRENT INCOME AND LIVING EXPENSES
Spouse Name:
3. List names, ages, and Social Security Numbers for all dependents residing in your home (attach additional pages
as necessary):
Name: Age:
Name: Age:
Name: Age:
Name: Age:
In order for the request for waiver to be approved, you must show that (a) it would cause you financial hardship, (b)
recovery would be unconscionable under the circumstances, or (c) because you expected a federal pandemic benefits
payment or received an incorrect federal pandemic benefits payment, you gave up a valuable right or changed positions
for the worse (in other words, you relied on the federal pandemic benefits payment when making a decision). Please use
the space provided below or an attached sheet to indicate what conditions exist that qualify you for a waiver of your
federal pandemic benefits overpayment. If the reason is due to medical complications, please enclose a medical statement.
There may be a glitch in the system for my overpayment. Due to covid restrictions my job as a food
delivery person ended & since my work dealt with in-person contact with people I was out of work.
Covid-19 breakout and pandemic restrictions caused me to file for unemployment. I am currently still
unemployed, and I hardly get gigs as a non-union actor, especially during the pandemic we're in. I'm
thankful and grateful for the program to help me get through for a bit while it did, but my bank account
barely has any money in it, I can hardly make ends meet, slowly trying to get back on my feet. So
please do waive this overpayment of mine. Thank you & God bless.
Xavier
Financial Statement
Other monthly gross income - Please list all income from each of the below categories and provide proof for each:
Social Security
Severance
Disability
Unemployment Compensation
Alimony
Child Support
TANF/Food Stamps
Other Income (please list) Worked as a non-union actor for a month and a half towards the
end of 2021. See paystubs attached.
Mortgage/Rent
Second Mortgage
Water
Gas
Electric
Cable
Internet
$90 per month
Medical/Dental
Telephone
$35 per month
Transportation (Car $100 in fuel per month, additional $100-$200 with maintenance
Payment, fuel, bus, every few months, oil change, tires, etc.
etc.)
Food
Groceries about $100 per month
Child Care
Student Loan(s)
Credit Card(s)
Home/Renter’s Insurance
Auto Insurance
$73 per month
Health Insurance
Life Insurance
TOTAL EXPENSES
About $300 - $400 a month
Bank Accounts - Please list all banks or financial institutions at which you have an account. Attach any additional bank
accounts on a separate page.
I understand that failure to answer the questions on this form truthfully may be considered unemployment insurance fraud. I
hereby certify that my answers to the questions on this form are true and correct.
I AFFIRM, UNDER THE PENALTIES OF PERJURY, THAT THE INCOME, EXPENSES, AND INFORMATION
LISTED ON THIS FORM ARE ACCURATE AND CORRECT.
When you have completed this form, please mail it and all attachments you wish to present to the following address: