UI / DE 4365TRA

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The Great Seal of The State of California

REQUEST FOR ELIGIBILITY INFORMATION

Mail Date:

MM/DD/YYYY

Name and Address of Claimant

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For Office Use Only:

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Your eligibility for unemployment insurance benefits beginning

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may be affected by information that

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***Your explanation of this information will determine whether or not you are entitled to benefits. Future claims you file may also be affected***

Write on the back of this form or attach a response to the information requested below. Include any other document or information you want us to consider. Mail your response to the Field Office address listed below.

Please answer the following questions:

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Please mail your response no later than

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, or a decision will be made based on available information.

Claims Interviewer

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Field Office Address

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DE 4365TRA Rev. 16 (3-22) (INTRANET)

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DE 4365TRA Rev. 16 (3-22) (INTRANET)

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UI / DE 4365TRA

REQUEST FOR ELIGIBILITY INFORMATION