UI / DE 4365MINOR

SAMPLE, this page for reference only

 
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
For Office Use Only:

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. The review of all available information may take up to three weeks to complete.

You must complete and mail this form along with the requested supporting documentation 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 and documentation:

  1. Your date of birth (MM/DD/YYYY):
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  2. Are you currently working, or did you work from 01/01/2020 to 12/31/2020?
  3. What type of employment, or self-employment do you normally perform?
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  4. What was the last date of your employment or self-employment (MM/DD/YYYY)?
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  5. Who did you last work for or perform services for?
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  6. Did you become unemployed due to COVID-19?
  7. Are you currently working or performing services in self-employment?
    If so, provide the name and phone number for who you are working for or performing services for:
    Blank line 

You must submit documentation to show proof of your current or prior employment or self-employment and/or work history along with this signed form. Evidence may include, but is not limited to, check stubs, canceled checks, IRS Form 1040 Schedule C or F, State Tax Return (CA Form 540), and/or W2.

COMPLETE THE INFORMATION ON THE BACK OF THIS FORM

DE 4365MINOR (1-21) (INTRANET)

SAMPLE, this page for reference only

Name of School or Educational Institution

  1. Provide the following information for the school or educational institution you attend:

    Name of school or educational institution:
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    Address:
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    Phone Number:
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    School Contact Person:
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  2. Normal Days and Hours of Attendance:

    Days:
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    Hours:
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Work Permit:

A work permit is a legal document required by the State of California that allows a person under 18 years of age to hold a job and issued by the California Department of Industrial Relations or by the school or educational institution that the minor attends.

Do you have a work permit?
Work permit valid from (MM/DD/YYYY):
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to (MM/DD/YYYY):
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Who issued the work permit to you?
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Non-Entertainment Industry Workers: You must provide unaltered copies of the originally approved:
  • Statement of Intent to Employ A Minor and Request for A Work Permit-Certificate of Age (CDE Form B1-1) and
  • Permit to Employ and Work (CDE Form B1-4).
Entertainment Industry Workers: You must provide unaltered copies of the originally approved:
  • Statement of Intent to Employ A Minor and Request for A Work Permit-Certificate of Age (CDE Form B1-1) and
  • Permit to Employ and Work (CDE Form B1-4) and
  • Entertainment Work Permit (DLSE-275), the permit status notification, and a copy of the Department of Justice report received.

Sign and date this form and mail it with the required documentation 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
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Print Your Name
(Parent or Legal Guardian)
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Signature
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Date

DE 4365MINOR (1-21) (INTRANET)