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UI / DE 1159SSSB
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SAMPLE
, this page for reference only
Notice of State Special Schools Benefit (SSSB) Claim Status
Mail Date:
Blank line
SSN:
XXX
-
XX
-
Blank space
Benefit Year Begins:
Blank line
PLEASE NOTE THE INFORMATION CHECKED BELOW REGARDING YOUR CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS
You have been disqualified from receiving regular unemployment benefits under the California Unemployment Insurance Code (CUIC) section
1253.3.
However, you are eligible to receive benefits under the State Special Schools Employee Unemployment Program. Refer to the section(s) checked below for award information.
(Refer to page
4
and
7
of your handbook entitled “A Guide to Benefits and Employment Services” for an explanation of how your benefit award is calculated.)
Your entitlement under the State Special Schools Benefit Claim is:
Maximum Benefit Award:
$
________
Blank line
Weekly Benefit Award:
$
________
Blank line
You are additionally eligible to receive a dual award based on your non-school wages. Your entitlement under your regular unemployment insurance claim is:
Maximum Benefit Award:
$
________
Blank line
Weekly Benefit Award:
$
________
Blank line
Your State Special School Benefits (SSSB) for the week(s) ending __________
Blank line
are not payable for the reason(s) checked below:
The week has been used as the unpaid waiting period on your claim.
Refer to page
11
of your for complete information regarding waiting periods.
The benefits payable for the week(s) are reduced because you reported earnings in excess of
$25.00.
The first
$25.00
or
25%
of the earnings (whichever is greater) is excluded in calculating the benefit amount payable.
Refer to pages
15-17
of your handbook for information on benefit reductions due to wages.
The benefits payable for the week(s) have been applied towards a disqualification that was previously assessed.
Refer to the “Notice of Determination” regarding this previously assessed disqualification or contact EDD for information on how to lift, remove, or serve the disqualification. For additional information on serving penalty weeks refer to page
26
of your handbook.
The benefits payable for the week(s) are reduced because you were unable to work for _____
Blank line
days during the week(s) due to your illness/injury.
Refer to page
19,
section
1
of your handbook for complete information benefit reduction due to injury/illness.
Other: _______________________
Blank line
Blank line
Department Representative
Special Claims Office—ARU 850 ▪ P.O. Box 419076 ▪ Sacramento, CA ▪ 95741-9076
Phone:
(916) 464-3300
▪ Fax:
(916) 464-3333
▪ TTY (Non-voice):
(916) 464-3355
▪
(916) 464-3307
DE 1159 SSSB (08-09)
Email Address:
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