UI / DE 2063

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

NOTICE OF REDUCED EARNINGS

LAST NAMEBlank space
FIRST NAMEBlank space
SOCIAL SECURITY NUMBER (SSN)Blank space
NOTE:
Issue a DE 2063 only for the seven-consecutive-day period corresponding to your payroll week. If you pay your workers less than once every seven days, you must issue a DE 2063 for each calendar week (Sunday through Saturday) of partial unemployment.
PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS.
EDD USE ONLY
Interviewer’s Initial
AC
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EMPLOYER’S STATEMENT FOR THE PAYROLL WEEKENDING DATE:
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(MM/DD/YY)
  1. Gross earnings (before deductions) were (if there were no earnings, enter Ø)
    $
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  2. Did this employee report for all work that was available during this payroll week?
    1. If the answer is “NO” give date(s)
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    2. REASON:
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  3. Why is this employee not working full-time? (Check one)
  4. Enter the last date this employee performed any work in your employment either on or prior to the payroll weekending date shown above:
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    (MM/DD/YY)
 
EMPLOYER CERTIFICATION:
I CERTIFY that the amount in Item 1 represents reduced earnings in a week of less than full-time work because of lack of work except as shown in Item 2.
ENTER
YOUR
 
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Company Name
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Phone Number
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Address
City
Zip Code
X
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Employer Signature
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Employer Account Number
DATE ISSUED TO EMPLOYEE:
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(MM/DD/YY)
ISSUE THIS FORM IMMEDIATELY AFTER PAYROLL WEEKENDING DATE SHOWN ABOVE
 
CLAIMANT:
You must complete this section. These questions and your answers are for the payroll weekending date(s) shown on the top of this form.
  1. Was there any reason other than lack of work why you couldn’t have worked full-time each regular workday that week?
    1. If yes, give reason, dates and time you could not work:
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  2. Did you work for anyone other than your regular employer on any day in that week? (This includes self-employment.)
    1. What is the employer’s name?
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      Address:
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    2. How much did you earn before deductions from that employer whether you were paid or not?
      $
      Blank line 
    3. Dates worked
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      to
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      Reason no longer working:
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  3. Are you receiving a pension, other than Social Security?
    1. If yes, has there been a change in the amount since you last reported it?
    2. If there has been a change, enter the new gross amount.
      $
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      Explain the reason for the change:
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  4. Did you have a change of address or telephone number in that week?
    1. If yes, please provide the information in the space below.
  5. If you want federal income tax withheld for that week, mark this block
 
CLAIMANT CERTIFICATION: I understand the questions on this form. I know the law provides penalties if I make false statements or withhold facts to receive benefits; my answers are true and correct. I declare under penalty of perjury that I am a U.S. citizen or national, or a non-citizen in satisfactory immigration status and permitted to work by the U.S. Citizenship and Immigration Services.
X
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Your Signature is Required
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Telephone Number
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Address
City
Zip Code
NOTE:
THIS CLAIM IS TIMELY ONLY BY CONTACTING THE EMPLOYMENT DEVELOPMENT DEPARTMENT WITHIN 28 DAYS AFTER ISSUED TO YOU. EXCEPTION: IF YOU KNOW THAT YOU WILL BE TOTALLY UNEMPLOYED IN EXCESS OF TWO CONSECUTIVE WEEKS, CONTACT EDD IMMEDIATELY.

DE 2063 Rev. 26 (8-10) (INTERNET)