UI / DE 731

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

EDD Telephone Numbers:
English:
‎1-800-300-5616
Spanish:
‎1-800-326-8937
Cantonese:
‎1-800-547-3506
Mandarin:
‎1-866-303-0706
Vietnamese:
‎1-800-547-2058
TTY (Non Voice):
‎1-800-815-9387

DECLARATION FOR ISSUANCE OF REPLACEMENT UNEMPLOYMENT INSURANCE CHECK

 
For Office Use Only
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Claim Date
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Program Code
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I,
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(First) (Middle) (Last)
, residing at
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(Street)
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(County)
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declare that I received or should have received the following unemployment insurance check(s) issued by the Employment Development Department (EDD), State of California, to the order of:
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(Payee)
and that said unemployment insurance check(s) were either lost, stolen, or destroyed.
No part of the amounts of the said checks has been received by me, either directly or indirectly, or applied to any use or purpose in my behalf. I agree to indemnify and hold harmless the State, its officers and employees, from any loss resulting from the issuance of said duplicate warrant or check.
I, therefore, ask that a new check(s) be issued in lieu of the one(s) that has been either lost, stolen, or destroyed, and in consideration of issuance, I HEREBY AGREE THAT IF I RECOVER THE ORIGINAL CHECK(S), I WILL NOT CASH SAME BUT WILL IMMEDIATELY CONTACT THE EMPLOYMENT DEVELOPMENT DEPARTMENT (EDD).
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
Executed on
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Month Day Year
, at
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City
, California.
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Claimant’s Signature
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EDD Representative
Return original, keep customer copy for your records.
DE 731 Rev. 22 (12-21) (INTRANET)