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SAMPLE, this page for reference only.
Either you or [Employer Name] told us you were fired (also known as terminated or discharged) for [dynamic text from macro]. This could affect your eligibility to receive unemployment benefits beginning MM/DD/YYYY.
Answer the questions as best as you can. If you believe you were not fired, tell us why in the Employment Questions. Your answers will help us determine your eligibility. You must mail this signed form and your supporting documents to the return address above by MM/DD/YYYY. If you prefer a telephone interview, call us at one of the above telephone numbers.
If you do not provide this information, you may be disqualified from receiving future unemployment benefits and you may be required to pay back the benefits you already received. If we determine that you intentionally gave false information or withheld information, you will have to pay an additional 30 percent penalty, and you may also be disqualified for future benefits for up to 23 weeks.
DE 4365FF Rev. 1 (12-23) (INTRANET)
How often were you paid? Select all that apply.
If Yes, complete the Separation Questions and the Employer Policy Questions below. If applicable, you must complete questions under Additional Eligibility Issues of this form or additional forms you may receive. After completing all required questions, sign and return this form.
{Dynamic fact-finding questions based on the type of separation}
While we determine your eligibility, continue to certify for benefits if you are unemployed or working reduced hours.
If you received at least one payment on your claim, but your payments have been pending for more than two weeks because of an eligibility issue, we will process a conditional payment as we continue reviewing the issue.
The fastest way to certify is through UI Online by visiting portal.edd.ca.gov. We will continue to pay you as long as you continue to certify, unless we find you are not eligible. Do not continue to certify if you are fully employed or believe you are not eligible for benefits. You may have to pay back any conditional payments you received if we later find you ineligible.
We may contact you if we need more information to determine your eligibility. It is important that you respond. If you do not respond, we will make a decision based on the information available to us. Without information from you, we may find you are not eligible for benefits. For more information, visit edd.ca.gov/claim-status.htm.
To be eligible to receive benefits, you must meet the eligibility requirements each week.
If we confirm your eligibility, we will send you an Additional Instructions (DE 238) notice, which will show the weeks that you were eligible for benefits
If you did not meet the eligibility requirements, we will send you a Notice of Determination, which you can appeal. You may have to pay back any overpayment you receive. An overpayment is when you collect benefits you are not eligible for.
For more information, visit edd.ca.gov/en/claims/benefit-overpayments.
You must mail this signed form and supporting documents to the address above by MM/DD/YYYY.
I understand that state law provides for financial penalties and disqualification weeks if I intentionally make false statements or withhold important facts to obtain benefits.
I declare under penalty of perjury that the information I am providing is true and correct.