UI / DE 1447CO-AZ

SAMPLE, this page for reference only.

State of California
EMPLOYMENT DEVELOPMENT DEPARTMENT
CENTRALIZED OVERPAYMENT
P.O. BOX 2228
RANCHO CORDOVA CA 95741-2228
1-866-401-2849

Notice of Potential Overpayment and False Statement Penalty

FIRSTNAME M LASTNAME
‎1234 SAMPLE ST APT 4321
MY CITY CA 99999-9999
Mail Date:
MM/DD/YYYY
BYB:
MM/DD/YYYY
NER Case No:
0000000000
During an audit of your unemployment benefits, your employer reported the earnings shown below. The earnings reported by your employer do not match the the benefit claim information you provided.
If you believe these earnings reported by your employer are incorrect, or if you have other information the Employment Development Department (EDD) should consider, immediately complete the enclosed response form and return it in the envelope provided.
If your response form is not received by MM/DD/YYYY, we will make a decision based on the available information, which will include information provided by your employer.
If you need help with your response, call ‎1-866-401-2849 Monday through Friday, from 8 am to 5 pm

Employer: Employer Name Inc.

-----Week----- ---Earnings---
Starting Ending Employer Reported You Reported Benefits Paid Potential Overpaid Amount
MM/DD/YYYY MM/DD/YYYY 000.00 ‎.00 000.00 000.00
MM/DD/YYYY MM/DD/YYYY 000.00 ‎.00 000.00 000.00
MM/DD/YYYY MM/DD/YYYY 000.00 ‎.00 000.00 000.00
Total Potential Overpayment: $ 000.00
30 Percent Penalty: 000.00
Total Amount: $ 000.00
Earnings for weeks ending MM/DD/YYYY include holiday pay.
If we find that you did not correctly report your earnings, you will receive an overpayment for the amount shown above. Additionally, because you did not report the earnings shown above, or did not report the correct amount of earnings, it appears that you may have intentionally provided the EDD with incorrect earnings or withheld earnings to be paid unemployment benefits. We need more information from you to help determine if you knew or should have known that the earnings you were providing to the EDD was incorrect, or if you withheld earnings on purpose, in order to be paid unemployment benefits. You can provide information about this potential false statement to the EDD in the enclosed response form and return it in the envelope provided.
DE 1447CO-AZ Rev. 3 (10-22) (INTERNET)

SAMPLE, this page for reference only.

 
NER Case No:
0000000000
If you do not provide information, the EDD will make a decision whether you made a false statement based on the information available.
If the EDD finds that you willfully and knowingly provided incorrect information or withheld information about your earnings so that you could 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 pay the 30 percent penalty shown above.
If you are hearing or speech impaired, contact the California relay service.
TDD users:
‎1-800-735-2929
Voice users:
‎1-800-735-2922
Department Representative:
(###/XXX)
DE 1447CO-AZ Rev. 3 (10-22) (INTERNET)