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UI / DE 3807
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SAMPLE
, this page for reference only
Notice of Determination or Assessment
Detach and return this stub with your payment to:
Employment Development Department
Cashiering Group, MIC 25
PO Box 826880
Sacramento, CA 94280-0001
Section 1142
Amount: $
Blank line
Section 1144
Amount: $
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Employer Name:
Blank line
Employer Account Number:
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Claimant's Name:
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Claimant's Last 4 of the SSA Number:
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Benefit Year Began:
Blank line
Separation Date:
Blank line
Claims Interviewer Initials:
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EDD Office Number:
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For EDD CO/CAS Use Only
Date Mailed to Employer:
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(Issue date of assessment)
Notice of Determination or Assessment
Employer Account Number
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______________
All available information has been considered. No penalty is assessed under
Section 1142
of the California Unemployment Insurance Code.
The Department has considered all available information and found that you or your employee, officer, or willfully made a false statement or representation or willfully failed to report a material fact concerning the termination of the claimant’s employment. For text of law and petition rights, see reverse side of this notice.
As required by
Section 1142
of the California Unemployment Insurance Code, you are assessed a penalty of
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___________
times the claimant’s weekly benefit amount of $
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____________.
The total amount of the assessment is $
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_____________.
A formal investigation by the Department resulted in the determination that you induced, solicited, or coerced a claimant to file a false or fraudulent claim for benefits. For text of law and petition rights, see reverse side of this notice.
As required by
Section 1144
of the California Unemployment Insurance Code, you are assessed a penalty equal to the liability established against the claimant(s) involved. In addition, any charges made to your reserve account for fraudulent claim(s) filed in relation to the assessment under
Section 1144
, are not relieved. The total amount of the assessment is $
Blank line
_____________.
Reason for Decision:
For Details About This Assessment, Please Call The EDD Office Listed On The Reverse Side Of This Notice
EDD Field Office Use Only:
Forward original to CO/CAS, MIC 3B (CAS will mail to employer). Date forwarded to CO/CAS:
Blank line
______________.
Forward copy to correspondence file.
DE 3807 Rev. 5 (11-21)
(INTRANET)
Email Address:
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