UI / DE 1447CO-BZ

SAMPLE, this page for reference only.

Response to Potential Overpayment and False Statement Penalty

Mail Date:
MM/DD/YYYY
Name:
FIRSTNAME M LASTNAME
 
 
NER Case No:
0000000000
Use this form to provide corrected or additional information about your potential overpayment or false statement penalty.
Complete and return this form by the date below if you do not agree with the earnings reported by your employers or you have other facts that should be considered, such as information about the potential false statement. Attach copies of any available records to support your information, such as time cards or check stubs that show your earnings during the weeks in question.
If your response form is not received by MM/DD/YYYY, we will make a decision based on the available information, including information provided by your employer. If you need more time, contact us at ‎1-866-401-2849 to extend the due date.
Information About Your Employment and Earnings
Employer:
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First day worked:
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Last day worked:
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Your earnings information or other facts:
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Information About Your Potential False Statement

Tell us why you believe your statement is correct by answering the following questions. We will contact you if we need additional information.

  1. Did you give us incorrect information to, 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?
    Blank line 
    Blank line 
DE 1447CO-BZ Rev. 3 (10-22) (INTRANET)
SAMPLE, this page for reference only.
NER Case No:
0000000000

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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Date
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Daytime Phone Number

Repayment of Overpaid Benefits and Change of Address

If you agree with the information reported by your employers but cannot pay in full, you may request a payment plan. Complete the section below and return this form in the envelope provided.

Blank Space (       ) Check here to request a payment plan.
If you have a change of address provide the new address below:
Blank line 
Blank line 
Make checks or money orders payable to Employment Development Department and send to the address below. Always write your Social Security number or your EDD Customer Account Number on all documents, checks, or money orders. Do not send cash through the mail.
 
EMPLOYMENT DEVELOPMENT DEPARTMENT
CENTRALIZED OVERPAYMENT
P.O. BOX 2228
RANCHO CORDOVA CA 95741-2228
DE 1447CO-BZ Rev. 3 (10-22) (INTRANET)