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SAMPLE, this page for reference only
Your eligibility for Unemployment Insurance (UI) benefits may be denied beginning MM/DD/YYYY . The EDD has identified an eligibility issue regarding your efforts to seek work. This form is being sent to gather information, which will allow the EDD to make an eligibility decision based on the available facts you will provide in this response. You are hereby advised that failure to provide the requested information within 10 days of the mailing date listed above may result in a disqualification of your FED-ED benefits.
On your claim form for week(s) ending MM/DD/YYYY MM/DD/YYYY you indicated you did not look for work. In order to be eligible for UI benefits, you are required to look for work during each week you are requesting UI benefits. The California Unemployment Insurance Code (CUIC) Section 1253(e) provides that an individual will be denied UI benefits if he or she does not look for work as required.
PLEASE COMPLETE AND MAIL THIS FORM TO THE EDD ADDRESS LISTED ABOVE.
Did you look for work for week(s) ending? MM/DD/YYYY MM/DD/YYYY
Provide a brief explanation about your work search efforts. This section is to be completed only if you marked “YES” to the question above. Once you have completed this section, sign and date the form in the box located in Section C.
Explain below what prevented you from seeking work by answering ALL of the following questions. This section is to be completed only if you marked “NO” to the question on the reverse side. Once you have completed this section, sign and date the form in the box located in Section C.
In order to be eligible for UI benefits, you must be able and available for work and actively seeking work each week you claim benefits. UI benefits may be denied in accordance with the CUIC 1253(c) if you are not able and available for work.
If Yes, what steps did you take? If No, explain why not.
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If No, please explain.
(Attach additional sheets if necessary. Always include your social security number on all additional documents.)
Sign and date below before mailing the form with the requested information to the address provided.
NOTICE
Under 18 U.S.C. § 1001, knowingly and willfully concealing a material fact by any trick, scheme, or device or knowingly making a false statement in connection with this claim is a Federal Offense, punishable by a fine of not more than $10,000 or imprisonment for not more than five years, or both.