UI / DE 4250DM (BAM)

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
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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 4250DM (BAM) Rev. 6 (8-24) INTRANET

SAMPLE, this page for reference only

Benefit Accuracy Measurement Claimant Questionnaire - Monetary Denial Claim

 
Batch #
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Sequence
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Sample Type
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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 UC and identifying general descriptive characteristics about the Unemployment Insurance (UI) 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 denied. This information will be verified. Pages 4 and 5 of this questionnaire are for recording your work history.
  1. Name (First, Middle, Last)
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    In the past three years, if you were known or earned income by another name, enter it here:
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  2. Social Security Number
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    In the past three years, if you earned income under another Social Security Number (SSN), enter the SSN here:
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  3. Street Address / Apt. Number
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  4. City, State, ZIP
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  5. Mailing Address (if different)
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  6. If you have moved since you first filed for unemployment benefits on
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    , enter your address when you first filed:
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  1. Telephone Number (include area code)
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  2. May we contact you via e-mail?
    If yes, please provide e-mail address:
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  3. Date of Birth (MM/DD/YYYY)
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  4. Gender:
  5. Race – Indicate by selecting one or more of the following:
  6. Ethnic Group – Indicate by selecting one of the following:

DE 4250DM (BAM) Rev. 6 (8-24) INTRANET

SAMPLE, this page for reference only

  1. US Citizen?
    If no, Country of Birth
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    City of Birth
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    Are you in the United States on a student visa?
    Do you have an alien registration card or other document?
    If yes, document number
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  2. Highest level of education completed (check box):
    Grade School
    High School
    Major Field of Study:
    Blank line
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  3. Have you had vocational or technical school training? If yes, do you have a certificate?
    Type of certificate:
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  4. Are you currently attending school or enrolled in a training program? If yes, complete the following: Name, Address, Phone Number of school or training program:
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    Do you have or can you obtain evidence that you are making satisfactory progress?
  5. In the last 18 months, what has been your usual occupation?
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    What are your main job duties at your usual work?
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  6. What is the type of work you are looking for?
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    Months/Years experience in this type of work:
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    Are you only seeking part time work?
  1. In the last 18 months, what has been your normal wage for the work you usually do?
    $
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    per
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    2. What is the lowest rate of pay you will accept for a job?
    $
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    per
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  2. Do 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?
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    When does it expire?
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  3. Were you entitled to any Social Security, pension, or retirement fund payments since the effective date of your current claim? If "Yes", give the amount received:
    $
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    $
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    $
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    $
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    $
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    $
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    $
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  4. Did you file for Unemployment Insurance (UI) beacuse you were required to do so by your local county welfare agency?
  5. How did you file your claim of
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    (New, AC, or Transitional)
  6. 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):



Please complete your work history on the following pages and sign the form.

DE 4250DM (BAM) Rev. 6 (8-24) INTRANET

SAMPLE, this page for reference only

Benefit Accuracy Measurement Claimant Questionnaire – Monetary Denial Claim Employment History Page 1
25. 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
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Month / Day / Year
Current or Most Recent
Employer Name
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Address
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Location of job site
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Telephone number
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Type of work(Check all that apply)
Supervisor/Title
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Length of Employment
First day
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Last day
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Your job title
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Your wages on this Job
$
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per
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What were your main job duties?
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Reason for seperation
2nd Most Recent
Employer Name
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Address
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Location of job site
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Telephone number
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Type of work(Check all that apply)
Supervisor/Title
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Length of Employment
First day
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Last day
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Your job title
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Your wages on this Job
$
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per
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What were your main job duties?
Blank line
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Reason for seperation
3rd Most Recent
Employer Name
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Address
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Location of job site
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Telephone number
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Type of work(Check all that apply)
Supervisor/Title
Blank line
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Length of Employment
First day
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Last day
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Your job title
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Your wages on this Job
$
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per
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What were your main job duties?
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Reason for seperation
4th Most Recent
Employer Name
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Address
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Location of job site
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Telephone number
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Type of work(Check all that apply)
Supervisor/Title
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Length of Employment
First day
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Last day
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Your job title
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Your wages on this Job
$
Blank line
per
Blank line
What were your main job duties?
Blank line
Blank line
Reason for seperation

DE 4250DM (BAM) Rev. 6 (8-24) INTRANET

SAMPLE, this page for reference only

Benefit Accuracy Measurement Claimant Questionnaire – Monetary Denial Claim Employment History Page 2
25. 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
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Your wages on this Job
$
Blank line
per
Blank line
What were your main job duties?
Blank line
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Reason for seperation
6th Most Recent
Employer Name
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Address
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Location of job site
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Telephone number
Blank line
Type of work(Check all that apply)
Supervisor/Title
Blank line
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Length of Employment
First day
Blank line
Last day
Blank line
Your job title
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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
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Address
Blank line
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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
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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
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Address
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Location of job site
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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 4250DM (BAM) Rev. 6 (8-24) INTRANET

SAMPLE, this page for reference only

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.
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Claimant's Signature
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Date Signed
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Interviewer's Signature
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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 4250DM (BAM) Rev. 6 (8-24) INTRANET