UI / DE 17RTW (BAM)

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Date:
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SSA Number:
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Batch Number:
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Final Notice

Congratulations on returning to work. Although you are back to work, we still need information from you. Enclosed you will find a Benefit Accuracy Measurement (BAM) Questionnaire that must be completed and returned within ten (10) days from the date of this notice. Please make sure you include your current employer information in the questionnaire.

Please include a copy of the following document(s):

Your benefits have been suspended effective
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, pending receipt and review of the questionnaire.

Completion of this questionnaire is required by department regulations. Failure to return the questionnaire may result in disqualification and loss of benefits under California Unemployment Insurance Code (CUIC) Section 1253A*.

(*An unemployed individual is eligible to receive unemployment compensation benefits with respect to any week only if the Director finds that: A claim for benefits with respect to that week(s) has been made in accordance with authorized regulations.)

You have ten (10) days from the date of this notice to return the questionnaire with a copy of the above document(s). The BAM Section will determine your eligibility based on all information received. If you have any questions or need assistance, please call the BAM Unit at
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Thank you for your cooperation.

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BAM Analyst #
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DE 17RTW (BAM) Rev. 1 (12-23) (INTRANET)