UI / DE 4464

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

FIELD OFFICE ADDRESS
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Date
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For Office Use Only
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Claimant's Name
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REQUEST FOR SEPARATION INFORMATION

 
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EDD Toll Free Telephone Numbers
English:
1-800-300-5616
Spanish:
1-800-326-8937
Cantonese:
1-800-547-3506
Mandarin:
1-866-303-0706
Vietnamese:
1-800-547-2058
TTY (non-voice):
1-800-815-9387
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Department Representative

Please complete this form and return it in the enclosed envelope within 10 days. NO POSTAGE IS REQUIRED.

We need to know the reason you stopped working for one of your former employers. The law requires us to rule whether the employer’s unemployment insurance (UI) account will be charged with your benefit payments and we need your assistance in answering the following questions:

 

SECTION A:
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(employer)
states your employment ended on
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(date)
because
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  1. Did you work for the above employer? If No, what was the name of the company you worked for at this same time?
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  2. How long did you work for the employer?
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  3. What kind of work did you do?
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  4. What hours did you work? From
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    AM or PM
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    AM or PM
    How many days a week?
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  5. Was the job:
  6. What was the last date you worked?
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    (Give approximate date if unsure.)
  7. What was your last rate of pay?
    ‎$
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    per:
  • If you QUIT the above job, please answer the questions in SECTION B below and on reverse side.
  • If you were DISCHARGED from the above job, please answer the questions in SECTION C on the reverse side.
  • If you DID NOT QUIT NOR WERE YOU DISCHARGED from the above job, complete SECTION D on the reverse side.

SECTION B: If you QUIT the job in SECTION A, please answer the following questions:

  1. Did you notify your employer that you were quitting? If Yes, whom did you tell you were quitting?
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    (name)
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    (title)
    What date?
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  2. Why did you quit? (If you quit for another job, complete next item, Item 3, on the reverse side.):
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PLEASE CONTINUE ON REVERSE SIDE

DE 4464 Rev. 32 (12-21) (INTRANET)

SAMPLE, this page for reference only

SECTION B: (Continued)

  1. If you quit for another job, complete "a" through "j" below:
  1. On what date did you know you had assurance of the new job?
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  2. Did you have a date to start work on your new job before leaving your old job?
    Date started:
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  3. Who offered you the new job?
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    (name)
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    (title)
  4. Who was the new employer?
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    (name of employer)
  5. New employer’s address:
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    (P.O. Box or street)
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    (city)
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    (state)
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    (ZIP code)
  6. What was the starting salary?
    $
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    per:
  7. What kind of work did you do?
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  8. Was the new job:
  9. New workdays:
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    New work hours:
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  10. If you did not start to work with the new employer, please explain:
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SECTION C: If you were DISCHARGED from the job in SECTION A, please answer the following:

  1. Who discharged you?
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    (name)
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    (title)
    What reason(s) were you given for your discharge?
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  2. Give your explanation for the discharge:
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  3. Were you warned your actions would lead to a discharge?
    If Yes, please explain:
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SECTION D: If you DID NOT QUIT NOR WERE YOU DISCHARGED from the job in SECTION A, explain why you did not continue working on the job in SECTION A:
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Your Signature:
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Date:
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Your Phone No.:
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(area code)

THANK YOU FOR YOUR COOPERATION

DE 4464 Rev. 32 (12-21) (INTRANET)