UI / DE 647

SAMPLE, this page for reference only.

EDD Employment Development Department State of California Logo

 
Declaration of Individual Claiming
Unemployment Insurance Benefits Due
(Deceased) (Incompetent) (Incapacitated) Claimant
For Office Use Only
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Claimant Name
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BYB
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DECLARATION OF INDIVIDUAL CLAIMING BENEFITS

I, (Name of Declarant)
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declare
1.
that (Name of (deceased) (incompetent) (incapacitated))
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, (died) (was legally declared incompetent) (became incapacitated) on (Date)
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2.
I am the (Relationship)
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of said (deceased) (incompetent) (incapacitated) claimant.
3.
I believe said (deceased) (incompetent) (incapacitated) claimant is eligible for unemployment insurance benefits, and because of his/her (death) (declaration of incompetence) (incapacitation), is unable to file a claim for benefits.
4.
I am the person legally entitled to receive any unemployment insurance benefits due, owing, and payable to said (deceased) (incompetent) (incapacitated) claimant on his/her behalf.
5.
I hereby request payment of the unemployment insurance benefits payable to the said (deceased) (incompetent) (incapacitated) claimant.
6.
I hereby request payment of the unemployment insurance benefits be sent to:
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I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

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Date
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Declarant’s Signature

Acknowledgment of Individual Claiming Benefits

Unemployment insurance benefit checks received by me may not be assigned and must be used, in accordance with the law, on behalf of and for the benefit of the (estate of the deceased) (incompetent) (incapacitated) claimant and for no other purpose.

  • I agree to repay the Employment Development Department (EDD) for any misapplication of benefits I receive for said (deceased) (incompetent) (incapacitated) claimant, and for any loss, expense, damage, or liability EDD incurs by reason of delivering the benefit check(s) to me.
  • I understand that cashing check(s) sent to me on behalf of the (estate of the deceased) (incompetent) (incapacitated) claimant will constitute a release of any and all claims the (deceased) (incompetent) (incapacitated) claimant may have against EDD for said benefits.
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Date
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Declarant’s Signature

DE 647 Rev. 25 (3-22) (INTERNET)

SAMPLE, this page for reference only.

Declaration of Physician Treating Mentally or Physically Incapacitated Claimants

(Name of incapacitated claimant)
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, is under my care and treatment. He/She became incapacitated on (Date)
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, and is unable to file his/her claim for unemployment insurance benefits because of his/her mental and/or physical incapacity.
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Print or type name as shown on license
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Signature of Attending Physician or Practitioner
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Address
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State License No.
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Telephone Number
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Date

DE 647 Rev. 25 (3-22) (INTERNET)