UI / DE 817D

SAMPLE, this page for reference only

 

DECLARATION UNDER PENALTY OF PERJURY FORGED ENDORSEMENT UNEMPLOYMENT INSURANCE CHECK

 
For Office Use Only:
Blank line 
Claim Date
Blank line 
Program Code
Blank line 
Office No.
Blank line 
Claimant/DeclarantBlank space 
 
Residence AddressBlank space 
 
CityBlank space 
StateBlank space 
Zip CodeBlank space 
Telephone NumberBlank space 
Issue DateBlank space 
Week(s) EndingBlank space 
Dollar Amount
$Blank space 
 
Warrant Or Check No.Blank space 
In Favor OfBlank space 
Purportedly Endorsed By:Blank space 
 
The endorsement on the above-cited warrant or check was not authorized or written by me and such endorsement of said warrant or check is a forgery. I have no knowledge of the endorsement of said warrant or check. No part of the money so paid by the State Treasurer at its Sacramento Office was received by me, directly or indirectly, and no part of said money was applied to any use or purpose in my behalf.
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
Executed on
Blank line
Month Day Year
, at
Blank line
City
, California.
(ORIGINAL SIGNATURE IS REQUIRED ON ALL DOCUMENTS)
Blank line 
Claimant’s Signature
Blank line 
EDD Representative
AUTHORIZATION (OPTIONAL)
 
I hereby authorize the Employment Development Department to disclose a copy of the above Declaration to law enforcement agencies, upon request, for purposes of a criminal investigation conducted by said law enforcement agencies into the forged endorsement matter raised by the above Declaration.
This authorization shall be valid and is to remain in effect for a period of six (6) months from the date of signature.
Blank line 
Claimant/Declarant Signature
Blank line 
Date
DO NOT WRITE IN SPACE BELOW
 
PAID BY STATE TREASURER ON: (Month, Day, Year) Blank line 
Contents examined and reissuance recommended:
Integrity and Accounting Division
By
Blank line 
Date
Blank line 
Approved:
Investigation Division
By
Blank line 
Date
Blank line 
PLEASE RETURN COMPLETED DOCUMENT IN ENCLOSED ENVELOPE
DE 817D Rev. 12 (10-22) (INTRANET)

SAMPLE, this page for reference only

 

DECLARATION UNDER PENALTY OF PERJURY FORGED ENDORSEMENT UNEMPLOYMENT INSURANCE CHECK

 
For Office Use Only:
Blank line 
Claim Date
Blank line 
Program Code
Blank line 
Office No.
Blank line 
Claimant/DeclarantBlank space 
 
Residence AddressBlank space 
 
CityBlank space 
StateBlank space 
Zip CodeBlank space 
Telephone NumberBlank space 
Issue DateBlank space 
Week(s) EndingBlank space 
Dollar Amount
$Blank space 
 
Warrant Or Check No.Blank space 
In Favor OfBlank space 
Purportedly Endorsed By:Blank space 
 
The endorsement on the above-cited warrant or check was not authorized or written by me and such endorsement of said warrant or check is a forgery. I have no knowledge of the endorsement of said warrant or check. No part of the money so paid by the State Treasurer at its Sacramento Office was received by me, directly or indirectly, and no part of said money was applied to any use or purpose in my behalf.
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
Executed on
Blank line
Month Day Year
, at
Blank line
City
, California.
(ORIGINAL SIGNATURE IS REQUIRED ON ALL DOCUMENTS)
Blank line 
Claimant’s Signature
Blank line 
EDD Representative
AUTHORIZATION (OPTIONAL)
 
I hereby authorize the Employment Development Department to disclose a copy of the above Declaration to law enforcement agencies, upon request, for purposes of a criminal investigation conducted by said law enforcement agencies into the forged endorsement matter raised by the above Declaration.
This authorization shall be valid and is to remain in effect for a period of six (6) months from the date of signature.
Blank line 
Claimant/Declarant Signature
Blank line 
Date
DO NOT WRITE IN SPACE BELOW
 
PAID BY STATE TREASURER ON: (Month, Day, Year) Blank line 
Contents examined and reissuance recommended:
Integrity and Accounting Division
By
Blank line 
Date
Blank line 
Approved:
Investigation Division
By
Blank line 
Date
Blank line 
PLEASE RETURN COMPLETED DOCUMENT IN ENCLOSED ENVELOPE
DE 817D Rev. 12 (10-22) (INTRANET)

SAMPLE, this page for reference only

 

DECLARATION UNDER PENALTY OF PERJURY FORGED ENDORSEMENT UNEMPLOYMENT INSURANCE CHECK

 
For Office Use Only:
Blank line 
Claim Date
Blank line 
Program Code
Blank line 
Office No.
Blank line 
Claimant/DeclarantBlank space 
 
Residence AddressBlank space 
 
CityBlank space 
StateBlank space 
Zip CodeBlank space 
Telephone NumberBlank space 
Issue DateBlank space 
Week(s) EndingBlank space 
Dollar Amount
$Blank space 
 
Warrant Or Check No.Blank space 
In Favor OfBlank space 
Purportedly Endorsed By:Blank space 
 
The endorsement on the above-cited warrant or check was not authorized or written by me and such endorsement of said warrant or check is a forgery. I have no knowledge of the endorsement of said warrant or check. No part of the money so paid by the State Treasurer at its Sacramento Office was received by me, directly or indirectly, and no part of said money was applied to any use or purpose in my behalf.
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
Executed on
Blank line
Month Day Year
, at
Blank line
City
, California.
(ORIGINAL SIGNATURE IS REQUIRED ON ALL DOCUMENTS)
Blank line 
Claimant’s Signature
Blank line 
EDD Representative
AUTHORIZATION (OPTIONAL)
 
I hereby authorize the Employment Development Department to disclose a copy of the above Declaration to law enforcement agencies, upon request, for purposes of a criminal investigation conducted by said law enforcement agencies into the forged endorsement matter raised by the above Declaration.
This authorization shall be valid and is to remain in effect for a period of six (6) months from the date of signature.
Blank line 
Claimant/Declarant Signature
Blank line 
Date
DO NOT WRITE IN SPACE BELOW
 
PAID BY STATE TREASURER ON: (Month, Day, Year) Blank line 
Contents examined and reissuance recommended:
Integrity and Accounting Division
By
Blank line 
Date
Blank line 
Approved:
Investigation Division
By
Blank line 
Date
Blank line 
PLEASE RETURN COMPLETED DOCUMENT IN ENCLOSED ENVELOPE
DE 817D Rev. 12 (10-22) (INTRANET)

SAMPLE, this page for reference only

 

DECLARATION UNDER PENALTY OF PERJURY FORGED ENDORSEMENT UNEMPLOYMENT INSURANCE CHECK

 
For Office Use Only:
Blank line 
Claim Date
Blank line 
Program Code
Blank line 
Office No.
Blank line 
Claimant/DeclarantBlank space 
 
Residence AddressBlank space 
 
CityBlank space 
StateBlank space 
Zip CodeBlank space 
Telephone NumberBlank space 
Issue DateBlank space 
Week(s) EndingBlank space 
Dollar Amount
$Blank space 
 
Warrant Or Check No.Blank space 
In Favor OfBlank space 
Purportedly Endorsed By:Blank space 
 
The endorsement on the above-cited warrant or check was not authorized or written by me and such endorsement of said warrant or check is a forgery. I have no knowledge of the endorsement of said warrant or check. No part of the money so paid by the State Treasurer at its Sacramento Office was received by me, directly or indirectly, and no part of said money was applied to any use or purpose in my behalf.
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
Executed on
Blank line
Month Day Year
, at
Blank line
City
, California.
(ORIGINAL SIGNATURE IS REQUIRED ON ALL DOCUMENTS)
Blank line 
Claimant’s Signature
Blank line 
EDD Representative
AUTHORIZATION (OPTIONAL)
 
I hereby authorize the Employment Development Department to disclose a copy of the above Declaration to law enforcement agencies, upon request, for purposes of a criminal investigation conducted by said law enforcement agencies into the forged endorsement matter raised by the above Declaration.
This authorization shall be valid and is to remain in effect for a period of six (6) months from the date of signature.
Blank line 
Claimant/Declarant Signature
Blank line 
Date
DO NOT WRITE IN SPACE BELOW
 
PAID BY STATE TREASURER ON: (Month, Day, Year) Blank line 
Contents examined and reissuance recommended:
Integrity and Accounting Division
By
Blank line 
Date
Blank line 
Approved:
Investigation Division
By
Blank line 
Date
Blank line 
PLEASE RETURN COMPLETED DOCUMENT IN ENCLOSED ENVELOPE
DE 817D Rev. 12 (10-22) (INTRANET)

SAMPLE, this page for reference only

 

DECLARATION UNDER PENALTY OF PERJURY FORGED ENDORSEMENT UNEMPLOYMENT INSURANCE CHECK

 
For Office Use Only:
Blank line 
Claim Date
Blank line 
Program Code
Blank line 
Office No.
Blank line 
Claimant/DeclarantBlank space 
 
Residence AddressBlank space 
 
CityBlank space 
StateBlank space 
Zip CodeBlank space 
Telephone NumberBlank space 
Issue DateBlank space 
Week(s) EndingBlank space 
Dollar Amount
$Blank space 
 
Warrant Or Check No.Blank space 
In Favor OfBlank space 
Purportedly Endorsed By:Blank space 
 
The endorsement on the above-cited warrant or check was not authorized or written by me and such endorsement of said warrant or check is a forgery. I have no knowledge of the endorsement of said warrant or check. No part of the money so paid by the State Treasurer at its Sacramento Office was received by me, directly or indirectly, and no part of said money was applied to any use or purpose in my behalf.
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
Executed on
Blank line
Month Day Year
, at
Blank line
City
, California.
(ORIGINAL SIGNATURE IS REQUIRED ON ALL DOCUMENTS)
Blank line 
Claimant’s Signature
Blank line 
EDD Representative
AUTHORIZATION (OPTIONAL)
 
I hereby authorize the Employment Development Department to disclose a copy of the above Declaration to law enforcement agencies, upon request, for purposes of a criminal investigation conducted by said law enforcement agencies into the forged endorsement matter raised by the above Declaration.
This authorization shall be valid and is to remain in effect for a period of six (6) months from the date of signature.
Blank line 
Claimant/Declarant Signature
Blank line 
Date
DO NOT WRITE IN SPACE BELOW
 
PAID BY STATE TREASURER ON: (Month, Day, Year) Blank line 
Contents examined and reissuance recommended:
Integrity and Accounting Division
By
Blank line 
Date
Blank line 
Approved:
Investigation Division
By
Blank line 
Date
Blank line 
PLEASE RETURN COMPLETED DOCUMENT IN ENCLOSED ENVELOPE
DE 817D Rev. 12 (10-22) (INTRANET)

SAMPLE, this page for reference only

 

DECLARATION UNDER PENALTY OF PERJURY FORGED ENDORSEMENT UNEMPLOYMENT INSURANCE CHECK

 
For Office Use Only:
Blank line 
Claim Date
Blank line 
Program Code
Blank line 
Office No.
Blank line 
Claimant/DeclarantBlank space 
 
Residence AddressBlank space 
 
CityBlank space 
StateBlank space 
Zip CodeBlank space 
Telephone NumberBlank space 
Issue DateBlank space 
Week(s) EndingBlank space 
Dollar Amount
$Blank space 
 
Warrant Or Check No.Blank space 
In Favor OfBlank space 
Purportedly Endorsed By:Blank space 
 
The endorsement on the above-cited warrant or check was not authorized or written by me and such endorsement of said warrant or check is a forgery. I have no knowledge of the endorsement of said warrant or check. No part of the money so paid by the State Treasurer at its Sacramento Office was received by me, directly or indirectly, and no part of said money was applied to any use or purpose in my behalf.
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
Executed on
Blank line
Month Day Year
, at
Blank line
City
, California.
(ORIGINAL SIGNATURE IS REQUIRED ON ALL DOCUMENTS)
Blank line 
Claimant’s Signature
Blank line 
EDD Representative
AUTHORIZATION (OPTIONAL)
 
I hereby authorize the Employment Development Department to disclose a copy of the above Declaration to law enforcement agencies, upon request, for purposes of a criminal investigation conducted by said law enforcement agencies into the forged endorsement matter raised by the above Declaration.
This authorization shall be valid and is to remain in effect for a period of six (6) months from the date of signature.
Blank line 
Claimant/Declarant Signature
Blank line 
Date
DO NOT WRITE IN SPACE BELOW
 
PAID BY STATE TREASURER ON: (Month, Day, Year) Blank line 
Contents examined and reissuance recommended:
Integrity and Accounting Division
By
Blank line 
Date
Blank line 
Approved:
Investigation Division
By
Blank line 
Date
Blank line 
PLEASE RETURN COMPLETED DOCUMENT IN ENCLOSED ENVELOPE
DE 817D Rev. 12 (10-22) (INTRANET)