UI/DE 4365LWA

SAMPLE, this page for reference only.

 

EDD Employment Development Department State of California Logo

RETURN TO:
STATE OF CALIFORNIA EMPLOYMENT DEVELOPMENT DEPARTMENT PO BOX 989130 WEST SACRAMENTO CA 95798-9130

Sample Client Name
‎1234 SAMPLE STREET
ANY TOWN, CA 9999-9999

 
SSN:
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EDDCAN:
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EDD Telephone Numbers:
English:
1-800-300-5616
Spanish:
1-800-326-8937
Cantonese:
1-800-547-3506
Mandarin:
1-866-303-0706
Vietnamese:
1-800-547-2058
TTY (Non-voice):
1-800-815-9387
EDD Internet Site:
edd.ca.gov

IMMEDIATE ACTION REQUIRED – LOST WAGES ASSISTANCE SELF-CERTIFICATION

This notice provides information regarding the Lost Wages Assistance (LWA) Program that was authorized as a result of the President’s Executive Order issued on August 8, 2020. The LWA program allows the Employment Development Department (EDD) to distribute ‎‎$300 in LWA benefits, under the Robert T. Stafford Disaster Relief and Emergency Assistance (Stafford) Act (Section ‎‎408 [e] [2], 42 U.S.C. 5174 [e] [2]), to eligible Unemployment Insurance (UI) claimants who meet all LWA requirements.

In order to be eligible for the ‎$300 in LWA benefits, you must:

  1. Have a Weekly Benefit Amount of ‎$100 or more on your unemployment insurance claim, AND
  2. Provide self-certification that you are unemployed or partially unemployed due to disruptions by COVID-19, AND
  3. Be eligible for payment with week ending dates starting on August 1, 2020. For information about your bi-weekly certifications, please log in to UI Online℠ to ensure that the certifications had been submitted.
IMPORTANT: Even if eligible, the EDD is only authorized, under the President’s Executive Order, to pay LWA benefits until funds are no longer available. This means that not all individuals will be able to receive this funding.

How do I provide my self-certification for the additional ‎$300 LWA benefit?

There are three ways that you can provide this self-certification for the ‎$300 LWA payment.
  1. Register in UI Online℠ and complete the online self-certification for faster processing. (Recommended)
  2. Submit a request online through Ask EDD.
  3. Complete this paper form and mail to the address above within 10 calendar days.
Failure to provide your self-certification will result in the delay or denial of LWA payment(s).

Actions to take for submitting the paper self-certification form.

STEP 1:
Answer the yes or no question below. Were you unemployed or partially unemployed due to disruptions by COVID-19?
Important: If you answer NO, you will not receive the additional ‎$300 LWA payment.
STEP 2: You must read the following statement and sign below. I declare under penalty of perjury that the information I have provided is true and correct to the best of my knowledge or belief, including the reason I am unemployed due to the COVID-19 pandemic. I understand that intentional misrepresentation in self-certifying the reason I am unemployed or partially unemployed due to COVID-19 is fraud and that I may be subject to criminal prosecution.
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Printed Name
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Signature
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Phone Number
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Date

DE 4365LWA (8-20) (INTRANET)