Unemployment Application Form – Fill Out and Use This PDF

Is the location or physical address of your very last employer the same as their mailing address? Yes

What are your gross wages for your last week of work (regular pay only)? $1,446.13

For UI purposes, a week begins on Sunday and ends the following Saturday. Whether you have been paid or not, report your total gross wages for your regular pay for the hours worked in the last week you worked, beginning w th Sunday and ending w th your last day of work as reported in question 3.

To calculate your total gross wages for your last week of work, multiply your hourly rate of pay by the total hours you worked from Sunday through the last day you worked (add piece work pay, if applicable).

Important!

If you were paid or if you will be pa d Holiday Pay, Vacation Pay, Severance Pay, In-Lieu-Of-Notice Pay, Other Pay (including, but not limited to, bonus pay, or commiss on pay), do NOT report these payments in question 4 as part of your gross wages. Report them separately in Other Payments quest on.

Reason No Longer Working: Laid Off/Lack of Work

Please provide a brief explanation (Maximum 150 characters): Part-time lecturer contract completed. No reasonable assurance of new work per EDD 1253.3(g).

If you received, or if you expect to receive, any payments from your very last employer or any other employer other than you regular salary, report the payment below.

Holiday Pay

Vacation Pay

Severance Pay

In-Lieu-Of-Notice Pay

Other Pay

Please explain Other Pay, if any (Maximum 150 characters):

Employment Information (Part 2 of 2)

Prov de your employment history for the past 18 months, including your very last employer. If you worked for a temporary agency, a labor contractor, an agent for actors, or an employer where wages are reported under a corporate name, your wages may have been reported under that employer name. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer.

Note: Failure to report all employers, periods of employment, and total wages may result in your benefits being delayed or denied. Provide as much accurate information as possible for each employer.

1-3. Did you work for another employer in the last 18 months? No

During the past 18 months, did you work for any other employers not listed above in quest on 1? No

Availability Information

Are you currently self-employed (have your own business or work as an independent contractor) or plan to become self-employed? Yes

If Yes:

Please explain (Maximum 150 characters): Self-employed The Bratten Company.Year-round work as independent contractor. Limited flexible hours that I set. Always available for full-time work.

Additional Information

In the past 2 years did you file a claim for Unemployment Insurance (UI) or Disability Insurance (DI)? Yes

If Yes: provide the most recent type(s) of claim(s) and date(s)

Are you receiving, or will you receive in the next year, a pension other than Social Security or Railroad Retirement, which is based on your own work or wages? No

Are you receiving or do you expect to receive Workers' Compensation? No

Are you currently attending or are you planning to attend school or training? No

Are you now or have you been in the last 18 months an officer of a corporat on or union or the sole or major stockholder of a corporation? No

D d you serve as elected publ c official or Governor-exempt appointee in the last 18 months? No

If the EDD finds that you do not have sufficient wages in the Standard Base Period to establish a valid UI claim, do you want to attempt to establish a claim using the Alternative Base Period? Yes

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