UI / DE 8591

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

FOR FO USE ONLY
FEMA #
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Disaster Name
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SELF-EMPLOYMENT INFORMATION

NAME
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SSN #
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PHONE #
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  1. SELF-EMPLOYED INDIVIDUAL
    1. Type of self-employment:
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      Business Name
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      Phone #
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      California Employer Acct. #
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      Mailing Address (Street or PO Box)
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      City
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      County
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      State
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      ZIP
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      Location of Business
      Street
      (if different than above)
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      City
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      County
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      Phone #
    4. Describe the nature of your self-employment
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    5. Were you performing any services in connection with this self-employment at the time the disaster occurred?
    6. If 'yes', average hours worked per week
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    7. Last date worked
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    8. At the time of the disaster, was this self-employment your primary means of support and primary occupation?
    9. If 'no', explain
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    11. If you have other employment or self-employment, how much time is devoted to other work?
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    12. If the business is scheduled to reopen, give the date it will reopen
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    13. Explain how the disaster affected your business
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SIGNATURE ON REVERSE. ALSO, IF YOU ARE SELF-EMPLOYED IN AGRICULTURE OR COMMERCIAL FISHING, COMPLETE SECTION B OR C ON REVERSE.

DE 8591 (1-97) (INTRANET)

SAMPLE, this page for reference only

  1. UNEMPLOYED SELF-EMPLOYED INDIVIDUALS IN AGRICULTURE
    1. If you were scheduled to engage in farming activities in the disaster area at the time of the disaster, please enter the date you were scheduled to begin farming operations
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    2. Percent of your time devoted to farm work
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    3. Percent of your time devoted to any other work or enterprise
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    4. Type of enterprise
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    5. Duration of crop
      (from)
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      (to)
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    6. Type of crop
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      Stage of crop
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  1. UNEMPLOYED SELF-EMPLOYED INDIVIDUALS IN COMMERCIAL FISHING
    1. If you were scheduled to engage in commercial fishing activities in the disaster area at the time of the disaster, please enter the date you were scheduled to begin those activities
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    2. Percent of your time devoted to fishing
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    3. Percent of your time devoted to any other work or enterprise
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    4. Type of enterprise
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    5. Please give the following information about your fishing activities:
       
    6. Inland
    7. Open Gulf
    8. Ocean
    9. Lease No.
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    10. Fishing License Expiration Date
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    11. What were you fishing for at time of disaster?
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I certify the information supplied on this form (front and reverse) for the purpose of obtaining Disaster Unemployment Assistance (DUA) is true and correct and that I am unemployed as a direct result of the disaster. I have been advised that these are Federal funds and that penalties are provided by law for willful misrepresentation or falsification of material facts in order to obtain benefits.

APPLICANT'S SIGNATURE:
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DATE:
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DE 8591 (1-97) (INTRANET)