UI / DE 4250P

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

Employment Development Department Unemployment Insurance (UI) Benefit Accuracy Measurement Program Authorization For Release of Information

I am a claimant for unemployment insurance benefits under the California Unemployment Insurance Code (CUIC), and I realize that it is necessary for the California Employment Development Department to verify certain information required by law in connection with my claim for unemployment insurance benefits. Such information includes, but is not limited to, medical records, military records, school records, and employment records from any former, present or prospective employer.

I hereby authorize the release, to the California Employment Development Department, of any information requested by that Department concerning my claim for unemployment insurance benefits.

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Name of Claimant
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Social Security Number
*Blank line 
Signature of Claimant
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Date

This Authorization shall remain in effect for six months from the date signed above.

Confidentiality Notice: This Notice is for the sole use of the intended recipients. It contains confidential or sensitive information. Under Penal Code 502 and Civil Code 1798.53, any unauthorized review, use, disclosure, or distribution of the content of this document is prohibited and subject to criminal penalties/fines. If you are not the intended recipient, please contact EDD.

 

DE 4250P Rev. 6 (7-24) INTRANET

SAMPLE, this page for reference only

Benefit Accuracy Measurement Claimant Questionnaire - Paid Claim

 
Batch #
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Sequence
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Analyst #
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Benefit Accuracy Measurement (BAM) audits randomly selected paid and denied Unemployment Compensation (UC) claims to verify their accuracy. Failures to report, disclose, or provide information when directed or to complete the BAM questionnaire by the due date may result in a delay or in a denial of benefits. Your responses are subject to state confidentiality statutes, which must conform to Federal regulations (20 CFR Part 603). State and Federal agencies safeguard the confidentiality of the BAM information by:

  1. using the information only for purposes of verifying claimant eligibility for Unemployment Compensation (UC) and identifying general descriptive characteristics about the Unemployment Insurance program;
  2. permitting access to the information by only authorized persons;
  3. ensuring that the physical and electronic storage of the information is secure; and
  4. publishing the results of the BAM audits in a format that precludes the identification of any individual providing the information.
Please answer the following questions as accurately as possible. If you do not know the answer, leave it blank. The interviewer will discuss it with you later. If you need help, please ask. Please print clearly. Your answers will be used to determine if your unemployment insurance benefits were properly paid. This information will be verified. Pages nine and ten of this questionnaire are for recording your work history.
  1. Name (First, Middle, Last)
    Blank line 
    In the past three years, if you were known or earned income by another name, enter it here:
    Blank line 
  2. Social Security Number
    Blank line 
    In the past three years, if you earned income under another Social Security Number (SSN), enter the SSN here:
    Blank line 
  3. Street Address / Apt. Number
    Blank line 
  4. City, State, ZIP
    Blank line 
  5. Mailing Address (if different) *
    *Blank line 
    Blank line 
    Blank line 
  6. If you have moved since you first filed for unemployment benefits on
    Blank Line 
    , enter your address when you first filed:
    Blank line 
    Blank line 
  7. Telephone Number (include area code)
    Blank line 
  1. May we contact you via e-mail?
    If yes, please provide e-mail address:
    Blank line
  2. Date of Birth (MM/DD/YYYY)
    Blank line
  3. Gender:
  4. Race – Indicate by selecting one or more of the following:
  5. Ethnic Group – Indicate by selecting one of the following:

DE 4250P Rev. 6 (7-24) INTRANET

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  1. US Citizen?
    If no, Country of Birth
    Blank line
    City of Birth
    Blank line
    Are you in the United States on a student visa?
    Do you have an alien registration card or other document?
    If yes, document number
    Blank line
  2. Highest level of education completed (check box):
    Grade School
    High School
    Major Field of Study:
    Blank line
    Blank line
  3. Have you had vocational or technical school training? If yes, do you have a certificate?
    Type of certificate:
    Blank line
  4. During "The week ofBlank lineto Blank line ," were you attending school or enrolled in a training program? If yes, complete the following: Name, Address, Phone Number of school or training program:
    Blank line
    Blank line
    Blank line
    Is the schooling or training related either to the type of work you usually do or the type of work you are seeking? Do you have or can you obtain evidence that you are making satisfactory progress?
  1. Check the days of the week you usually work.
    Do you usually work part time?
  2. Check the days of the week you are willing and able to work.
    Are you only seeking part time work?
  3. What hours or shifts do you usually work?
  4. What hours are you willing and able to work on a job?
    From Blank line am To Blank line pm
    Or
    From Blank line am To Blank line pm
  5. Which shifts are you willing and able to work on a job?
  6. In the last 18 months, what has been your normal wage for the work you usually do?
    $
    Blank line
    per
    Blank line
  7. What is the lowest rate of pay you will accept for a job?
    $
    Blank line
    per
    Blank line
  8. In the last 18 months, what has been your usual occupation?
    Blank line
    What are your main job duties at your usual work?
    Blank line
    Blank line

DE 4250P Rev. 6 (7-24) INTRANET

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Work Search
The next group of questions asks about your efforts to find work. Some of these questions will refer to a specific week, called "The Week." "The Week" is the week that began on Blank line and ended on Blank line Please keep these dates in mind when answering the questions about "The Week." 
  1. Do you expect to be called back to work by any past employer?
    If yes, please answer the following: Do you have or have you received a recall notice?
    When were you told you would be recalled?
    Blank line 
    (Date)
    How were you notified?
    Blank line
    Who notified you? (Name, title, and telephone)
    Blank line
    When will you report back to work?
    Blank line
    Name, Address, and phone number of employer
    Blank line
    Blank line
    Blank line
  2. How many miles are you willing to travel one-way daily to a job?
    Blank line
  3. How many minutes or hours are you willing to travel one-way daily to a job?
    Blank line
  4. Do you have a valid driver’s license?
    Driver’s License No.:
    Blank line
  5. By what means do you normally travel to look for work? (check all that apply)
    Do you have transportation to get to and from a job?
  6. Would a job have to last a certain period of time before you would accept it?
    If yes, explain:
    Blank line
    Blank line
    Blank line
  1. What is the type of work you are looking for?
    a.
    Blank line
    b.
    Blank line
    What is the length and type of experience you have in these occupations?
    a.
    Blank line
    b.
    Blank line
    2. 32a.
  2. Have you registered with the State Employment Service (CalJOBS℠) to find work since you first filed for unemployment benefits on Blank line?
    If yes, answer the following:
    3. 32b.
  3. What was the date you completed or updated the resume?
    Blank line
    4. 32c.
  4. How did you file your resume?
    5. 33.
  5. If residing out of state, have you registered with the state employment agency?
    6. 34.
  6. During "The Week," did the State Employment Service (CalJOBS℠) refer you to any jobs?
    If yes, what were the results of these referrals?
    Blank line
    Blank line
    Blank line
    Have you received any referrals from the State Employment Services (CalJOBS℠) since you opened your current claim?
    If yes, to how many jobs were you referred?
    Blank line

DE 4250P Rev. 6 (7-24) INTRANET

SAMPLE, this page for reference only

"The Week" is the week that began on Blank line and ended on Blank line

  1. Have you registered with a private employment agency since you first filed for unemployment benefits on
    Blank line 
    ?
    If yes, when did you register with the agency?
    Blank line 
    Name, Address, Phone Number of Agency:
    Blank line 
    Blank line 
    Blank line 
    Blank line 
    During "The Week,"  did the Agency refer you to any jobs?
    If yes, to how many jobs were you referred?
    Blank line 
    What were the results of these referrals?
    Blank line 
    Blank line 
    Blank line 
  2. During  "The Week,"  were you an active member of a union?
    If yes, complete the following:
    Union Name:
    Blank line
    Local Number:
    Blank line
    Address:
    Blank line
    Blank line
    Phone Number:
    Blank line
    Does your union have a local hiring hall?
    Are your dues considered current?
    Whom do you contact at the local:
    Blank line
    Do you get work only through the union?
    Will you accept a non-union job?
    During "The Week," were you eligible to be referred to jobs by the union?
    If no, explain:
    Blank line
    Blank line
    Blank line
    During "The Week," were you on the out-of-work list?
    If yes, when was the last time you signed the list?
    Blank line
    If no, explain:
    Blank line
    Blank line
    Blank line
    During "The Week," how many jobs were you referred to by the union?
    Blank line
    What were the results of these referrals?
    Blank line 
    Blank line 
  1. During "The Week," did you or a member of your immediate family have any health problem, handicap or disability that limited your ability to do your usual work or to look for work?
    If yes, explain:
    Blank line
    Blank line
    Blank line

DE 4250P Rev. 6 (7-24) INTRANET

SAMPLE, this page for reference only

"The Week" is the week that began on Blank line and ended on Blank line

  1. During "The Week," did you have any dependent(s) or other person(s) for whom you provided care during your normal working hours?
    If no, go to Question 39.
    If yes, was there some other person or place available to provide care?
    If yes, provide the name, address, and phone number of the care provider:
    Blank line 
    Blank line 
    Blank line 
  2. During "The Week," was there any day(s) that you were not available for work?
    If yes, list the day(s) and reason(s) you were not available:
    Blank line 
    Blank line 
    Blank line 
  1. During "The Week," was there any reason that you could not accept full-time work?
    If yes, explain:
    Blank line 
    Blank line 
    Blank line 
  2. During "The Week," were you an officer of a corporation, union, or other organization?
    If yes, give name of organization and office held:
    Blank line 
    Blank line 
    Blank line 
  3. During "The Week," did you need any special licenses or certificates to do the type of work you are seeking?
    If yes, do you have the license or certificate needed?
    What kind of license or certificate is it?
    Blank line 
    When does it expire?
    Blank line 

DE 4250P Rev. 6 (7-24) INTRANET

SAMPLE, this page for reference only

43a. Work Search Contacts
Complete the following information for the job contacts you made during "The Week." If you had more than four job contacts, the interviewer will give you another worksheet. List all job contacts you made during "The Week," including those with unions, private employment agencies, and the State Employment Service.
"The Week" is the week that began on Blank line and ended on Blank line
1. Employer Name
Blank line
Blank line
Address
Blank line
City/State/Zip
Blank line
Contact Date
Blank line
Name
Blank line
Title
Blank line
Employer Phone (include area code)
Blank line
Type of work applied for
Blank line
Method of Contact
Blank line
Application taken? Resume submitted?
Was a job offered? Result
Blank line
2. Employer Name
Blank line
Blank line
Address
Blank line
City/State/Zip
Blank line
Contact Date
Blank line
Name
Blank line
Title
Blank line
Employer Phone (include area code)
Blank line
Type of work applied for
Blank line
Method of Contact
Blank line
Application taken? Resume submitted?
Was a job offered? Result
Blank line
3. Employer Name
Blank line
Blank line
Address
Blank line
City/State/Zip
Blank line
Contact Date
Blank line
Name
Blank line
Title
Blank line
Employer Phone (include area code)
Blank line
Type of work applied for
Blank line
Method of Contact
Blank line
Application taken? Resume submitted?
Was a job offered? Result
Blank line
4. Employer Name
Blank line
Blank line
Address
Blank line
City/State/Zip
Blank line
Contact Date
Blank line
Name
Blank line
Title
Blank line
Employer Phone (include area code)
Blank line
Type of work applied for
Blank line
Method of Contact
Blank line
Application taken? Resume submitted?
Was a job offered? Result
Blank line
43b. Please indicate any other job development activities you engaged in during "The Week" (such as networking, resume writing, visiting Web sites or employment agencies, job clubs, etc.)
Blank line
Blank line
Blank line

DE 4250P Rev. 6 (7-24) INTRANET

SAMPLE, this page for reference only

43b. Work Search Related Activities
Please check all the job development activities you engaged in during "The Week" (such as networking, resume writing, visiting websites, employment agencies, job clubs, etc.)
"The Week" is the week that began on Blank line and ended on Blank line
  1. Provide name(s) and date(s) for all that apply:
    Friends
    Name(s): Blank Line
    Date: Blank Line
    Family
    Name(s): Blank Line
    Date: Blank Line
    Associates
    Name(s): Blank Line
    Date: Blank Line
  2. Date: Blank Line
  3. Searched the internetWebsite name(s):Blank Line
    Date: Blank Line
    Had an active resume on a job search website:Website name(s):Blank Line
    Date: Blank Line
    Registered with a Professional/Social networking website (e.g., LinkedIn)Name(s):Blank Line
    Date: Blank Line
  4. Source name(s):Blank Line
    Date: Blank Line
  5. Name(s) and/or location(s): Blank Line
    Date: Blank Line
  6. Name(s): Blank Line
    Date: Blank Line
Agency Use Only (Additional Comments):
Blank Line 
Blank Line 

DE 4250P Rev. 6 (7-24) INTRANET

SAMPLE, this page for reference only

"The Week" is the week that began on Blank line and ended on Blank line

  1. During "The Week," did you get any job offers either from the contacts you listed in question 43 or from contacts you made in previous weeks?
    If yes, did you accept any jobs offered to you?
    If no, why not?
    Blank line 
    Blank line 
    Blank line 
    If yes, complete the following:
    Date you accepted the offer:
    Blank line 
    Date you began or will begin work:
    Blank line 
    Name, address, and phone number of employer:
    Blank line 
    Blank line 
    Blank line 
  2. During "The Week," did you do work of any kind?
    If yes, what type of work did you do?
    Blank line 
    Blank line 
    Blank line 
    Days and times worked:
    Blank line 
    Blank line 
    Blank line 
    Name, address, and phone number of employer:
    Blank line 
    Blank line 
    Blank line 
    Blank line 
    Are you still working for this employer?
    If no, provide the reason you are no longer employed:
    Blank line 
    Blank line 
    Blank line 
    Blank line 
  1. Check all of the following sources of income you had during "The Week," excluding unemployment compensation, and list the amount you received from each source for "The Week," even if you were paid at some other time.
    If none, go to Question 47
    $
    Blank line
    $
    Blank line
    $
    Blank line
    $
    Blank line
    $
    Blank line
    $
    Blank line
    $
    Blank line
    $
    Blank line
    $
    Blank line
    $
    Blank line
    $
    Blank line
    (do not include Social Security or Veteran’s Benefits)
    $
    Blank line
    Blank line
    $
    Blank line
  2. During "The Week," were you entitled to any Social Security, pension, or retirement fund payments?
    If no, go to Question 48.
    If yes, give the amount received:
    $
    Blank line
    $
    Blank line
    $
    Blank line
    $
    Blank line
    $
    Blank line
    $
    Blank line
    $
    Blank line
    $
    Blank line

Please complete your work history on the following pages

DE 4250P Rev. 6 (7-24) INTRANET

SAMPLE, this page for reference only

Benefit Accuracy Measurement Claimant Questionnaire – Nonseparation Denial Claim Employment History Page 1
48. Please provide the following information about employers for whom you worked. Begin with your most recent employer and work back to the date shown. Include all employment (i.e. full time, part time, out of state, federal employment or contract work). From the present back to
Blank line 
Month / Day / Year
Current or Most Recent
Employer Name
Blank line
Blank line
Address
Blank line
Blank line
Location of job site
Blank line
Telephone number
Blank line
Type of work (Check all that apply)
Supervisor/Title
Blank line
Blank line
Length of Employment
First day
Blank line
Last day
Blank line
Your job title
Blank line
Your wages on this Job
$
Blank line
per
Blank line
What were your main job duties?
Blank line
Blank line
Reason for seperation
2nd Most Recent
Employer Name
Blank line
Blank line
Address
Blank line
Blank line
Location of job site
Blank line
Telephone number
Blank line
Type of work (Check all that apply)
Supervisor/Title
Blank line
Blank line
Length of Employment
First day
Blank line
Last day
Blank line
Your job title
Blank line
Your wages on this Job
$
Blank line
per
Blank line
What were your main job duties?
Blank line
Blank line
Reason for seperation
3rd Most Recent
Employer Name
Blank line
Blank line
Address
Blank line
Blank line
Location of job site
Blank line
Telephone number
Blank line
Type of work (Check all that apply)
Supervisor/Title
Blank line
Blank line
Length of Employment
First day
Blank line
Last day
Blank line
Your job title
Blank line
Your wages on this Job
$
Blank line
per
Blank line
What were your main job duties?
Blank line
Blank line
Reason for seperation
4th Most Recent
Employer Name
Blank line
Blank line
Address
Blank line
Blank line
Location of job site
Blank line
Telephone number
Blank line
Type of work (Check all that apply)
Supervisor/Title
Blank line
Blank line
Length of Employment
First day
Blank line
Last day
Blank line
Your job title
Blank line
Your wages on this Job
$
Blank line
per
Blank line
What were your main job duties?
Blank line
Blank line
Reason for seperation

DE 4250P Rev. 6 (7-24) INTRANET

SAMPLE, this page for reference only

Benefit Accuracy Measurement Claimant Questionnaire – Nonseparation Denial Claim Employment History Page 2
48. Please provide the following information about employers for whom you worked. Begin with your most recent employer and work back to the date shown. Include all employment (i.e. full time, part time, out of state, federal employment or contract work). From the present back to
Blank line 
Month / Day / Year
5th Most Recent
Employer Name
Blank line
Blank line
Address
Blank line
Blank line
Location of job site
Blank line
Telephone number
Blank line
Type of work (Check all that apply)
Supervisor/Title
Blank line
Blank line
Length of Employment
First day
Blank line
Last day
Blank line
Your job title
Blank line
Your wages on this Job
$
Blank line
per
Blank line
What were your main job duties?
Blank line
Blank line
Reason for seperation
6th Most Recent
Employer Name
Blank line
Blank line
Address
Blank line
Blank line
Location of job site
Blank line
Telephone number
Blank line
Type of work (Check all that apply)
Supervisor/Title
Blank line
Blank line
Length of Employment
First day
Blank line
Last day
Blank line
Your job title
Blank line
Your wages on this Job
$
Blank line
per
Blank line
What were your main job duties?
Blank line
Blank line
Reason for seperation
7th Most Recent
Employer Name
Blank line
Blank line
Address
Blank line
Blank line
Location of job site
Blank line
Telephone number
Blank line
Type of work (Check all that apply)
Supervisor/Title
Blank line
Blank line
Length of Employment
First day
Blank line
Last day
Blank line
Your job title
Blank line
Your wages on this Job
$
Blank line
per
Blank line
What were your main job duties?
Blank line
Blank line
Reason for seperation
8th Most Recent
Employer Name
Blank line
Blank line
Address
Blank line
Blank line
Location of job site
Blank line
Telephone number
Blank line
Type of work (Check all that apply)
Supervisor/Title
Blank line
Blank line
Length of Employment
First day
Blank line
Last day
Blank line
Your job title
Blank line
Your wages on this Job
$
Blank line
per
Blank line
What were your main job duties?
Blank line
Blank line
Reason for seperation

DE 4250P Rev. 6 (7-24) INTRANET

SAMPLE, this page for reference only

Benefit Accuracy Measurement Claimant Questionnaire – Paid Claim
  1. How did you file your claim of
    Blank line 
    (New, AC, or Transitional prior to KW)
  2. Did you receive information about your unemployment benefits, rights, and responsibilities when you first filed for benefits? If yes, how was the information given to you? (Check all that apply):



  1. Have you had any problems with your unemployment insurance claim?
    If yes, explain:
    Blank line
    Blank line
    Blank line
  2. Do you have any questions to ask about your unemployment insurance claim or about your responsibilities and rights as an unemployment insurance claimant?
    If yes, explain:
    Blank line
    Blank line
    Blank line
    Blank line
    Blank line
    Blank line
53. Between the day you filed for unemployment benefits and the day that you completed this questionnaire, have you worked for any employers? . If no, stop, go to signature If yes, please provide the name, address, and telephone number for this employer.
Blank line
Blank line
Blank line
Are you still working for this employer? If no, why are you no longer working for this employer?
Blank line
Blank line
Blank line
Blank line
I have understood the questions on this questionnaire and I have answered them truthfully to the best of my knowledge. I know my answers will be used to determine if my unemployment benefits were paid properly. I know the law provides penalties for false statements made to obtain benefits. I also know that my answers will be verified.
Blank line 
Claimant's Signature
Blank line 
Date Signed
Blank line 
Interviewer's Signature
Blank line 
Date Signed
Agency Use Only Information obtained by:
1st Attempt:Blank line / Blank line / Blank line
2nd Attempt:Blank line / Blank line / Blank line
3rd Attempt:Blank line / Blank line / Blank line

DE 4250P Rev. 6 (7-24) INTRANET