UI / DE 4365PQ

SAMPLE, this page for reference only.

 

EDD Employment Development Department State of California Logo

Request for Training Provider Information for California Training Benefits (CTB) Program Eligibility

EDD UI Toll-Free Phone Numbers:
English:
1-800-300-5616
Spanish:
1-800-326-8937
Mandarin:
1-866-303-0706
Vietnamese:
1-800-547-2058
Cantonese:
1-800-547-3506
TTY:
1-800-815-9387
Self-Service:
1-866-333-4606
EDD Website:
www.edd.ca.gov
 
Mail Date:
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For Office Use Only:
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You are receiving this Request for Training Provider Information for California Training Benefits (CTB) Program Eligibility, DE 4365PQ, because attempts to contact the representative who authorized or sponsored your training were unsuccessful by phone. Attending school or training may affect your eligibility to receive Unemployment Insurance (UI) benefits unless your school or training plan is approved by the Employment Development Department (EDD) under the CTB program.

UI BENEFITS CANNOT BE PAID UNTIL YOUR CTB ELIGIBILITY IS DETERMINED BY THE EDD.

WHAT YOU NEED TO DO

  • Take this form to your authorized training program sponsor, training provider, employer or union representative to complete sections A, B, and C.
  • Return the completed form by mail within ten (10) calendar days of the mail date of this notice to the address listed above.

WHAT YOUR AUTHORIZED TRAINING PROVIDER MUST DO

  • Follow the instructions on this form and complete sections A, B, and C.
  • Return the form to the student named above.

WHAT HAPPENS NEXT

Your CTB eligibility will be determined when this completed form is received and processed by the EDD or at the end of 10 calendar days from the mail date of this form, whichever occurs first. Failure to return this form completed and signed within 10 calendar days may result in denial of UI benefits.

DE 4365PQ Rev. 3 (12-21) (INTRANET)

SAMPLE, this page for reference only.

INSTRUCTION FOR AUTHORIZED TRAINING PROGRAM SPONSOR, TRAINING PROVIDER, EMPLOYER, OR UNION REPRESENTATIVE.

Complete sections A, B, and C for the student named above. The term ‘training program’ refers to both vocational training programs and degree programs. The information you provide will be used to validate the training information obtained from the student by the EDD in order to determine his/her eligibility to receive UI benefits under the CTB program while attending training.

A. SCHOOL OR TRAINING PROGRAM

  1. Is the student’s training program authorized, sponsored, or funded by one of the following programs?
    1. The Federal Workforce Innovation and Opportunity Act (WIOA)
    2. The Federal Trade Adjustment Assistance Program (TAA)
    3. The California Employment Training Panel (ETP)
    4. The California Work and Responsibilities to Kids (CalWORKs) program
  2. Are the student’s specific training institution and training program on the Eligible Training Provider List (ETPL)?
  3. Is the training for a single subject credential in math, science, or special education?
    If yes, enter credential type:
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  4. Is the student’s training program authorized by his or her labor union?
    If yes, is the student an active journey level or a master union member and in good standing?
    Union Name:
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    Union Local Number:
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    Union Representative Name:
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    Union Phone Number:
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  5. Is the student’s training program authorized by his or her trade association?
    Is the claimant a journey level trade association member?
    Trade Association Representative Name:
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    Trade Association Representative Phone Number:
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    Name of Training Program:
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  6. Is the training funded or sponsored by the employer?
    Is the Employer’s training industry related?
    If yes to both questions, complete the following:
    Employer Name:
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    Employer/Training Representative Name:
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    Title
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    Employer/Training Representative Phone Number:
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  7. Is the claimant attending a long-term state or federal approved apprenticeship training?
    Training Representative Name:
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    Title:
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    Phone Number:
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  8. What is the name of the school or training facility the student is attending?
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  9. Where is the training facility located? (If the student attends multiple facilities then provide the primary facility he/she attends.)
    Address:
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    City
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    County:
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    State
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    ZIP Code
    Blank line 

DE 4365PQ Rev. 3 (12-21) (INTRANET)

SAMPLE, this page for reference only.

  1. What is the phone number of the training facility?
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  2. What is the name and title of the contact, if available?
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  3. What is the name of the training program that the student is attending?
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  4. If the training program leads to an industry related license, credential, or certification, provide the type of license, credential, or certificate.
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  5. Which occupations will the student be able to look for upon completing the specified training program?
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  6. When did the student first begin attending the training program?
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  7. What date is the student expected to complete the entire period of training, including any intern or externships?
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  8. How many units, credits, or hours per week is the student taking?
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  9. How many units, credits, or hours does the student need in order to complete the school or training program?
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  10. Is the student’s school attendance or training considered full-time?
  11. Does the school or training program offer a summer session during the months of June, July, and/or August?
    1. If Yes, will/is the student attending school during the summer session?
    2. If No, what are the dates of the summer recess period when the student will not be attending school or training?
      Blank line  to Blank line
  12. What are the dates of any scheduled recess periods and/or breaks other than the summer recess period that will occur during the student’s school attendance or training?
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  13. If the training facility operates on a semester or quarter basis, provide the beginning and ending dates of each period up to the student’s date of completion.
    Blank line  to Blank line
    Blank line  to Blank line

B. DISCRETIONARY FUNDS

Under Section 1273 of the California Unemployment Insurances Code (CUIC), students who are receiving any discretionary federal or state training or retraining benefits, allowances or stipends paid by the training provider or the funding source for the training program, will not have their training approved under the CTB program and may not be eligible to receive UI benefits. The student has been advised that he or she must waive the receipt of discretionary funds in order to be eligible.
Discretionary Funds is defined as money for any use or purpose an individual chooses. Direct and indirect funds for training costs, books, and/or supplies are not considered discretionary funds.
If the student is receiving discretionary funds, answer questions a and b.
  1. Briefly explain the amount and purpose of the discretionary funds.
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  2. Has the student waived the receipt of those funds?

DE 4365PQ Rev. 3 (12-21) (INTRANET)

SAMPLE, this page for reference only.

C. TRAINING INFORMATION CERTIFICATION

Provide your organization information if you are an authorized representative of WIOA, TAA, ETP, CalWORKs or a trade association or labor union.
Organization Name:
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Address:
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City
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County:
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State
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ZIP Code
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I certify the information I provided on this form concerning the above-mentioned student’s training enrollment is true and correct.
Representative Name:
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Representative Title:
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Phone
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Representative Signature:
Blank line 
Date Signed
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EDD Contact Information

If you have any questions about this form or if you need to make any corrections to the information provided above, then you can contact the EDD online at www.edd.ca.gov, select the “Contact EDD” link and select either “Jobs and Training” or “Unemployment Insurance Benefits” or by calling one of the toll-free numbers listed on the front of this form.

RETURN INSTRUCTIONS FOR STUDENT

YOU MUST RETURN THE COMPLETED QUESTIONNAIRE WITHIN TEN (10) CALENDAR DAYS FROM THE MAIL DATE OF THIS NOTICE (LISTED ON THE FRONT OF THIS FORM) BY MAIL USING THE ENCLOSED ENVELOPE TO THE EDD.

DE 4365PQ Rev. 3 (12-21) (INTRANET)