UI / DE 4365PFS-T

SAMPLE, this page for reference only

Mail Date:
MM/DD/YY
000 0000
Benefit Year Beginning Date:
MM/DD/YY
For Office Use Only:
00000

Notice of Potential False Statement

Why am I receiving this notice?

You are receiving this notice because information available to the EDD indicates that you may have provided the EDD with incorrect information or withheld information related to the potential eligibility issue indicated in the attached Notice of Potential Overpayment.

What is the penalty if EDD determines I made a false statement?

If the EDD finds that you willfully and knowingly provided incorrect information or withheld information to be paid benefits, you could receive 2 to 23 “false statement” penalty weeks. These penalty weeks will be added to your current or future unemployment claim. For each of the penalty weeks, you must be fully or partially unemployed, submit certifications, and meet all eligibility requirements, but you will not be paid benefits for those weeks. You may also have to repay any prior benefits you received and pay a monetary penalty equal to 30% of the total amount of benefits you were overpaid.

How can I provide information to the EDD about this possible false statement?

If you would like to provide information regarding your potential false statement, you may answer the questions below, sign and date this notice, and mail it back to the address shown below within 10 days of the mail date on the Notice of Potential Overpayment. The answers you provide will help the EDD to determine if you knew or should have known that the information you were providing to the EDD was incorrect, or if you withheld information on purpose, in order to be paid unemployment benefits.

If you prefer to respond in writing, answer the following questions as completely as possible:

  1. Did you give us incorrect information, or withhold information from the EDD?
  2. If you provided incorrect information, did you know that the information you provided was incorrect at the time you provided that information?
  3. If you withheld information, did you know you should have provided that information to EDD at the time you provided that information?
  4. If you discovered the information you provided was incorrect, did you attempt to notify the EDD?
  5. If you answered yes to question 1, why did you provide the incorrect information or withhold the information?
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  6. Do you have any other information to add?
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I understand that state law provides for financial penalties and disqualification weeks if I intentionally make false statements or withhold important facts to obtain benefits.

I declare under penalty of perjury that the information I am providing on this notice is true and correct.

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Signature
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Printed Name
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Date
Return this completed form to:
EDD
Address
City, State, Zip Code
DE 4365PFS-T (9-22) (INTRANET)