UI / DE 4365PFS

SAMPLE, this page for reference only

Mail Date:
[Claimant First and Last Name]
Benefit Year Beginning Date:
For Office Use Only:
Employment Development Department
PO BOX 1234
ANY TOWN, CA 99999-9999

Notice of Potential False Statement

Why am I receiving this notice?

You are receiving this notice because information available to the EDD indicates that you may have provided the EDD with incorrect information or withheld information related to the other potential eligibility issue that will be discussed during your scheduled phone interview.

To help you prepare for the interview, below are questions that you may be asked by the EDD. The answers you provide will help the EDD to determine if you knew or should have known that the information you were providing to the EDD was incorrect, or if you withheld information on purpose, in order to be paid unemployment benefits.

What is the penalty if EDD determines I made a false statement?

If the EDD finds that you willfully and knowingly provided incorrect information or withheld information to be paid benefits, you could receive 2 to 23 “false statement” penalty weeks. These penalty weeks will be added to your current or future unemployment claim. For each of the penalty weeks, you must be fully or partially unemployed, submit certifications, and meet all eligibility requirements, but you will not be paid benefits for those weeks. You may also have to repay any prior benefits you received and pay a monetary penalty equal to 30% of the total amount of benefits you were overpaid.

Can I provide the answers to these questions in writing?

If you would like to provide the answers to these questions regarding your potential false statement in writing instead of during the phone interview, you may answer the questions below, sign and date this notice, and mail it back to the address shown above within 10 days of the mail date on the Notification of Unemployment Insurance Benefits Eligibility Interview.

Even if you choose to respond to these questions in writing, you must still be available for the scheduled phone interview at the date and time shown on the Notification of Unemployment Insurance Benefits Eligibility Interview to discuss the other potential eligibility issue shown in the notice. Additionally, the EDD may contact you to clarify the answers you provide on this notice.

If you prefer to respond in writing, answer the following questions as completely as possible:

  1. Did you give us incorrect information, or withhold information from the EDD?
  2. If you provided incorrect information, did you know that the information you provided was incorrect at the time you provided that information?
  3. If you withheld information, did you know you should have provided that information to EDD at the time you provided that information?
  4. If you discovered the information you provided was incorrect, did you attempt to notify the EDD?
  5. If you answered yes to question 1, why did you provide the incorrect information or withhold the information?
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  6. Do you have any other information to add?
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I understand that state law provides for financial penalties and disqualification weeks if I intentionally make false statements or withhold important facts to obtain benefits.

I declare under penalty of perjury that the information I am providing on this notice is true and correct.

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Signature
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Printed Name
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Date
DE 4365PFS (9-22) (INTRANET)