UI / DE 4365INC

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 
 
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
Mail Date:
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For Office Use Only:
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REQUEST FOR ELIGIBILITY INFORMATION

There is a question about your eligibility for Unemployment Insurance (UI) benefits beginning MM/DD/YYYY. This request is being sent to gather information from you to help the Employment Development Department (EDD) make a decision regarding your eligibility for unemployment benefits. The review of all available information may take up to three weeks to complete.

You must complete and mail this form to the EDD address listed above by MM/DD/YYYY.

Failure to provide verifiable information may result in your disqualification from receiving future UI benefits and you may be required to pay back the UI benefits you already received. You may also be assessed additional penalties as provided for under the law.

You must provide the following information:

Are you currently, or have been, incarcerated from January 1, 2020 to December 31, 2020?

  1. Provide dates of incarceration:

    Admission (MM/DD/YYYY):
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    Release (MM/DD/YYYY):
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    Scheduled Release (MM/DD/YYYY):
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  2. Name of Facility/Institution:
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  3. If you were incarcerated and receiving UI benefits, why haven’t you told the EDD that you were not able and available for work?
    Blank line  
    Blank line  
  4. Were you employed prior to your incarceration date?

COMPLETE THE INFORMATION ON THE BACK OF THIS FORM

DE 4365INC (1-21) (INTRANET)

SAMPLE, this page for reference only

Employment Information:

When you filed your claim you told the EDD you were employed and/or self-employed.

  1. Provide the following information regarding your last employer and/or self-employment:

    Address:
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    Phone:
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    Contact Person:
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    Type of work you performed:
    Blank line  

  2. What dates did you work for the employer, including self-employment?

    Start (MM/DD/YYYY):
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    End (MM/DD/YYYY):
    Blank line  
  3. Why are you no longer working for this employer?
    Blank line  
  4. If you did not work for the employer listed above, why haven’t you told the EDD that you did not work for this employer?
    Blank line  
    Blank line  

Release Status Information:

The California Unemployment Insurance Code (CUIC) section 1253c states “A claimant is available for work during the week for which he or she claims benefits if the claimant is ready, willing, and able to accept suitable employment or has good cause for any restriction on his or her readiness, willingness, or ability to accept such employment and; notwithstanding such a restriction, a substantial field of employment remains open to the claimant in his or her labor market”.

  1. Are you currently on parole or in probation status?
    Provide parole/probation release date (MM/DD/YYYY):
    Blank line  
  2. If released, are there restrictions on your availability for work?

Sign and date this form before mailing it to the EDD address provided above.

I understand the law provides penalties if I make false statements or withhold facts to obtain benefits. I declare under penalty of perjury that the information I am providing is true and correct.
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PRINT YOUR NAME
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SIGNATURE
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DATE

DE 4365INC (1-21) (INTRANET)