Edd Unemployment Form – Fill Out and Use This PDF

THIS NOTICE WAS MAILED TO THE EMPLOYER/ADDRESS LISTED BELOW ON:

New Claim:

Additional Claim:

EDD Telephone Number: 1-800-300-5616

TTY (Non-Voice):

1-800-815-9387

IMPORTANT: NOTICE OF UNEMPLOYMENT INSURANCE CLAIM FILED

This is a notice that a claim for unemployment insurance benefits has been filed. Forward it immediately to persons within your

organization who are responsible for handling claims. The time limit for replying is 10 days from the mail date shown above.

Failure to respond may result in an increased Employment Tax Rate.

The claimant provided us with the following information and listed you as his/her last employer:

Claimant's Name	Social Security Number	Effective Date of Claim:
Reason for Separation:		Last Date Worked:

I. EXPLANATION AND INSTRUCTIONS FOR EMPLOYERS

You have received this form because the individual shown above has filed a claim for unemployment insurance benefits and has listed

you as his/her most recent employer prior to filing this claim. No reply is required if the claimant was laid off due to lack of work and

no other eligibility issue has been identified. For detailed information on employer responsibilities in the unemployment insurance program, our DE 44, California Employer's Guide, is available upon request.

II. REPORTING FACTS - Respond in writing by completing Sections A, B, C on the reverse of this form.

The law requires an employer to submit any facts in his/her possession which may affect a claimant's eligibility for benefits. Furnish information if this claimant:

A Department representative may contact you for further eligibility information. If a representative is unable to reach you, he/she may leave a message for you to return the telephone call. If after 48 hours no response has been received, the Department is required to make an eligibility decision based on available information.

III. TIME LIMITS FOR REPLYING

Submit facts in writing to the field office shown at the top of this form within 10 days of the mail date shown above. If your mailing is late, explain your reasons for delay as the time limit may be extended only for good cause. You may reply on this form in the

space provided in Section IV, on additional sheets as needed, or by separate letter. Always include your State Employer Account Number and include the claimant's Social Security Number as it appears on the claim and in your payroll records.

If you submit facts in a timely manner, a determination will be issued concerning the claimant's eligibility. In addition, if facts are sub-

mitted regarding a quit or discharge, a ruling will be issued advising an employer with a reserve account as to whether his/her account will be subject to changes resulting from benefits paid. To obtain a ruling on any prior quit or discharge involving this claimant, you must

furnish facts within 10 days of the mail date shown above.

ADDITIONAL INFORMATION ON EMPLOYER RESPONSIBILITIES IS SHOWN ON THE REVERSE Mail your response to the EDD office shown in the above upper left-hand corner.

(OVER)

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IV. REPORTING ELIGIBILITY INFORMATION: Do not return this form unless Sections A or B are completed. It is necessary to complete Section C for all responses.

A.REPORTING FACTS:

Claimant Social Security Number

-

-

Date Last Worked was:

-

-

(from your payroll records)

(Month

Day

Year)

B. OTHER COMPENSATION:

Complete the following if you paid or will pay any compensation, aside from regular salary, covering any time on or after the effective date of this claim. No entry is required if the claimant has been separated from your employ for any indefinite period and has or will receive only vacation pay.

Amount $

Type of Payment

for period from

through

C. EMPLOYER CERTIFICATION: THE ABOVE STATEMENTS WERE TAKEN FROM BUSINESS RECORDS OR ARE BASED ON KNOWLEDGE

OF THE UNDERSIGNED.

PRINT name of person to contact for further information:

Name of contact:

Telephone No. (

)

-

Ext.

Employer:

Date:

STATE EMPLOYER

-

ACCOUNT NO.:

Signed By:

V. ELIGIBILITY DETERMINATION

It may be necessary to contact you by telephone or letter for eligibility information if an issue is identified by the field office. Regardless of whether such contact is made however, unless you respond to the notice by mail as described in this notice, you will not be entitled to a

written notice of the Department's decision.

IMPORTANT:

of facts that may affect the eligibility of the claimant and facts could not reasonably have been known within the period. However, you must provide the Department with these facts within 10 days of acquiring them.

fact in connection with a separation issue may be assessed a penalty of up to 10 times the claimant's weekly benefit amount. Section 1142(b) provides that an employer who willfully makes a false statement or representation or willfully fails to report a material fact in submitting a written statement concerning reasonable assurance of a claimant's reemployment, as defined in Section 1253.3(g), may be assessed a penalty of up to 10 times the claimant's weekly benefit amount.

ÅSection 2101 of the UI Code provides that it is a misdemeanor to willfully make a false statement or knowingly fail to disclose a material fact to obtain, increase, reduce, or defeat any payment of benefits.

PLEASE MAIL YOUR RESPONSE TO THE EDD OFFICE AND ADDRESS SHOWN IN THE UPPER LEFT-HAND CORNER ON THE REVERSE SIDE OF THIS FORM.

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