UI / DE 1200

SAMPLE, this page for reference only.

DateBlank space
Claimant/Employee NameBlank space
Social Security Number
XXX-XX-
EDD Field OfficeBlank space

BACK PAY AWARD INFORMATION REQUEST

Employer or Claimant name and address:

We have been informed that the claimant named above may receive a back pay award. Back pay is considered wages for unemployment insurance purposes and is allocated to the period for which it is awarded. If Unemployment Insurance (UI) benefits have been paid for this period, an overpayment must be established.

If the back pay award agreement stipulates that the employer will reduce the back pay award by the amount of UI benefits paid for that period, section 1382 of the Unemployment Insurance Code requires the employer to repay the benefits to the Employment Development Department (EDD). Information regarding the amount of UI benefits paid during the period covered by the back pay award may be obtained from the Overpayment Specialist at the EDD office shown above.

The claimant/employee is liable for repayment of the affected UI benefits if the amount of the benefits is not withheld from the award.

Please submit the following information to the EDD office shown above, to enable EDD to determine the amount of UI benefits overpaid, and the party responsible for repayment.

The award was for (check one):
Hourly rate of pay
$
Number of hours worked per week
Gross amount of back pay award
$
Period covered by award
Amount withheld due to UI benefits received
$
Date back pay issued

Claimant: A Notice of Overpayment will be mailed to you, indicating whether or not you are responsible for repayment of the overpayment.

Employer: If you reduced the back pay award by the amount of UI benefits received, please mail payment to:

Employment Development Department
Document Management Section, MIC 96
P.O. Box 826880
Sacramento, CA 94280-0001
 

Include the claimant/employee’s name and Social Security number, your Reserve Account number, and indicate that the payment is for a back pay award.

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EDD Representative

DE 1200 Rev. 3 (7-21) (INTERNET)