UI / DE 8595DUA

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

REQUEST FOR RECOMPUTATION OF DISASTER UNEMPLOYMENT ASSISTANCE BENEFIT AWARD

NAME
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FOR OFFICE USE ONLY
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You may request a recomputation of your benefit award by providing employment wages or self-employment earnings information along with proof of those wages/earnings at any time during the Disaster Assistance Period, but not later than
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Acceptable documentation includes, but is not limited to: check stubs, W-2, 1099, federal and state income tax forms, letter from employer.

Enter your wages or earnings for each quarter of your most recently completed tax year since the day you first became unemployed as a direct result of the disaster. Example: Last day worked was October 1997, the most recently completed tax year is 1996.

Base period
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QTR 1 Begins (Date)
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Ends (Date)
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Amount
$Blank line 
QTR 2 Begins (Date)
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Ends (Date)
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Amount
$Blank line 
QTR 3 Begins (Date)
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Ends (Date)
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Amount
$Blank line 
QTR 4 Begins (Date)
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Ends (Date)
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Amount
$Blank line 

In addition, if you are self-employed, please provide the following:

Quarter Estimated Tax
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Gross Earnings
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Subsidies
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Subtotal
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Business Expenses
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NET EARNINGS
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(From IRS 1040 Schedule C, line 31)
If, during your most recently completed tax year, you had additional wages as an employee to add to your claim provide the name and address of the employer(s) and the wage amount
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I certify the information supplied on this form for the purpose of obtaining Disaster Unemployment Assistance (DUA) is true and correct and that I am unemployed as a direct result of the disaster. I have been advised that these are Federal funds and that penalties are provided by law for willful misrepresentation or falsification of material facts in order to obtain benefits.

Signature:
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Date:
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DE 8595DUA Rev. 2 (12-21)