UI / DE 4365ER

SAMPLE, this page for reference only

Employment Development Department
Orange Adjudication Center - MZK
PO Box 6600
Anaheim, CA 92816-6000

Name and address of claimant:

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Mail Date:
SSN:

REQUEST FOR ELIGIBILITY INFORMATION

There is a question about your eligibility for Unemployment Insurance (UI) benefits beginning Blank line Your eligibility for UI benefits may be affected.
The EDD has information that an employer(s) reported in the base period of your claim and/or an employer you reported that you last worked for is not legitimate and you did not work for the employer(s). The EDD needs to determine the validity of the employment before further UI payments can be made to you. This request is being sent to gather information from you to help the EDD make a decision regarding your eligibility for unemployment benefits. The review of all available information may take up to six weeks to complete.
Failure to provide the information requested in this notice by
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will result in you being disqualified from receiving future UI benefits and you will be required to pay back the UI benefits you already received. If you respond and the EDD cannot validate the information you provide, you will also be disqualified from receiving UI benefits and will be required to pay back the benefits you already received. In either case, you may also be assessed additional penalties as provided for under the law.
YOU MUST COMPLETE AND MAIL THIS FORM ALONG WITH THE REQUESTED SUPPORTING DOCUMENTATION TO THE EDD ADDRESS LISTED ABOVE BY
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Your UI claim effective
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is based in full or in part on wages from
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The EDD has information that this employer is not a valid employer. If you have information that this employer is valid and you did work for this employer, then provide the required information below. You must include evidence that you performed work for the employer. Evidence includes, but is not limited to, check stubs and/or W2s. If the validity of the employment cannot be verified, the wages reported by this employer will be removed from the base period of your claim and you will be liable for an overpayment of any UI benefits you received. You may also be assessed additional penalties as provided for under the law.
Name of Base Period Employer:
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  1. Provide the following information for the employer listed above:
    Address:
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    Phone:
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    Contact person:
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    Type of work you performed:
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DE 4365ER Rev. 1 (11-17) (INTRANET)

SAMPLE, this page for reference only

REQUEST FOR ELIGIBILITY INFORMATION

  1. What dates did you work for this employer?

    Start (MM/DD/YYYY):
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    End (MM/DD/YYYY):
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  2. How much gross wages did you earn from this employer?

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  3. Why are you no longer working for this employer?

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  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?
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YOU MUST SUBMIT DOCUMENTATION OF THIS EMPLOYMENT (FOR EXAMPLE, PROOF OF EMPLOYMENT AND WAGES) ALONG WITH THIS FORM. IF YOU DO NOT RESPOND OR IF THE EDD IS UNABLE TO VALIDATE THE EMPLOYER(S) INFORMATION YOU PROVIDE, YOU WILL BE DISQUALIFIED FROM RECEIVING UI BENEFITS AND WILL BE REQUIRED TO PAY BACK ANY UI BENEFITS YOU RECEIVED. YOU MAY ALSO BE ASSESSED ADDITIONAL PENALTIES AS PROVIDED FOR UNDER THE LAW.

When you filed your claim with the effective date
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, you told the EDD that your last employer was
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The EDD has information that this employer is not a valid employer. If you have information that this employer is valid and you did work for this employer, then provide the required information below. You must include evidence that you performed work for the employer. Evidence includes, but is not limited to, check stubs and/or W2s.
  1. Provide the following information for
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    Address:
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    Phone:
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    Contact person:
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    Type of work you performed:
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  2. What dates did you work for this employer?

    Start (MM/DD/YYYY):
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    End (MM/DD/YYYY):
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  3. Why are you no longer working for this employer?

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DE 4365ER Rev. 1 (11-17) (INTRANET)

SAMPLE, this page for reference only

REQUEST FOR ELIGIBILITY INFORMATION

  1. If you did not work for this employer, answer the following questions:

    1. Why did you tell the EDD this was your last employer?

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    2. Who was your correct last employer at the time you filed your claim?

      Name:
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      Address:
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      Phone:
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      Contact person:
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      Type of work you performed:
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      Last day you worked:
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      Reason you are no longer working for this employer:

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YOU MUST SUBMIT DOCUMENTATION OF THIS EMPLOYMENT (FOR EXAMPLE, PROOF OF EMPLOYMENT AND WAGES) ALONG WITH THIS FORM. IF YOU DO NOT RESPOND OR IF THE EDD IS UNABLE TO VALIDATE THE EMPLOYER(S) INFORMATION YOU PROVIDE, YOU WILL BE DISQUALIFIED FROM RECEIVING UI BENEFITS AND WILL BE REQUIRED TO PAY BACK ANY UI BENEFITS YOU RECEIVED. YOU MAY ALSO BE ASSESSED ADDITIONAL PENALTIES AS PROVIDED FOR UNDER THE LAW.

If you have additional information that you would like to share with the EDD regarding these employer(s) or your eligibility for UI benefits, please provide that information in this section. Attach additional sheets if necessary. Always include your Social Security number on all additional documents.

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Sign and date below before mailing the form with the requested information to the address provided.

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 4365ER Rev. 1 (11-17) (INTRANET)