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SAMPLE, this page for reference only

UNEMPLOYMENT INSURANCE APPLICATION

FILING INSTRUCTIONS

Complete this application including any applicable attachment(s). Print or type the information. Use blue or black ink only.
Answer all questions on each page. Review your application thoroughly for completeness. An incomplete application may delay or prevent the filing of your claim, or cause benefits to be denied. If the Employment Development Department (EDD) needs to verify any of the information you provide while filing a claim, you will receive additional forms by mail and will be asked to provide additional information and/or documentation.

APPLICATION QUESTIONS

The answers you give to the questions on this application must be true and correct. You may be subject to penalties if you make a false statement or withhold information.

Question	Answer
1. Did you work in a state other than California during the last 18 months? AND/OR	1. Yes No If yes, check the applicable box(es) below: State(s) Outside California, specify state(s): Blank line Blank line
Did you work in Canada during the last 18 months?	Canada
2. What is your Social Security number as given to you by the Social Security Administration?	2. Blank Box Blank Box Blank Box - Blank Box Blank Box - Blank Box Blank Box Blank Box Blank Box
a) If the EDD assigned you an EDD Client Number (ECN), please provide the ECN here. (An ECN is a 9-digit number beginning with 999 or 990.)	a) Blank Box Blank Box Blank Box - Blank Box Blank Box - Blank Box Blank Box Blank Box Blank Box
2A. List any other Social Security numbers you have used.	2A. Blank Box Blank Box Blank Box - Blank Box Blank Box - Blank Box Blank Box Blank Box Blank Box Blank Box Blank Box Blank Box - Blank Box Blank Box - Blank Box Blank Box Blank Box Blank Box
3. What is your full name?	3 Last Blank line First Blank line Middle Initial Blank line
4. Is this the name that appears on your Social Security card?	4. Yes No
a)If no, provide the name that appears on your Social Security card.	a) Last Blank line First Blank line Middle Initial Blank line
5. List any other names you have used.	5. Blank line Blank line
6. What is your birth date?	6. Blank line (mm/dd/yyyy)
7. What is your gender?	7. Male Female
8. What is your written language preference?	8. English Spanish Other Blank line
a)What is your spoken language preference?	a) English Spanish Other Blank line
9. Have you filed a California Unemployment Insurance or a Disability Insurance claim in the last two years?	9. Yes No
a)If yes, list each type of claim and the most recent date(s) of when the claim(s) was filed.	a)Unemployment Claim Date(s) (mm/dd/yyyy) Blank line Blank line Blank line a)Disability Claim Date(s) (mm/dd/yyyy) Blank line Blank line Blank line

1.

Did you work in a state other than California during the last 18 months?
AND/OR

1.

Yes No

If yes, check the applicable box(es) below:

State(s) Outside California, specify state(s):

Blank line

Did you work in Canada during the last 18 months?

Canada

2.

What is your Social Security number as given to you by the Social Security Administration?

2.

-

a) If the EDD assigned you an EDD Client Number (ECN), please provide the ECN here. (An ECN is a 9-digit number beginning with 999 or 990.)

a)

-

2A.

List any other Social Security numbers you have used.

2A.

-

3.

What is your full name?

3

Last

Blank line

First

Blank line

Middle Initial

Blank line

4.

Is this the name that appears on your Social Security card?

4.

Yes No

a)If no, provide the name that appears on your Social Security card.

a)

Last

Blank line

First

Blank line

Middle Initial

Blank line

5.

List any other names you have used.

5.

Blank line

6.

What is your birth date?

6.

Blank line

(mm/dd/yyyy)

7.

What is your gender?

7.

Male Female

8.

What is your written language preference?

8.

English Spanish

Other

Blank line

a)What is your spoken language preference?

a)

English Spanish

Other

Blank line

9.

Have you filed a California Unemployment Insurance or a Disability Insurance claim in the last two years?

9.

Yes No

a)If yes, list each type of claim and the most recent date(s) of when the claim(s) was filed.

a)Unemployment Claim Date(s) (mm/dd/yyyy)

Blank line

a)Disability Claim Date(s) (mm/dd/yyyy)

Blank line

DE 1101ID Rev. 6 (6-22) (INTERNET)

SAMPLE, this page for reference only

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number:

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Question	Answer
10. Do you have a Driver License issued to you by a State/entity?	10. Yes No
a)If yes, provide the name of the issuing State/entity and your Driver License number.	a) Name of issuing State/entity: Blank line ____________ Driver License Number: Blank line _________
If no, answer questions b‑d:	If no, answer questions b‑d:
b) Do you have an Identification Card issued to you by a State/entity?	b) YesNo
c) If yes, provide the name of the issuing State/entity and your Identification Card number.	c) Name of issuing State/entity: Blank line ____________ Identification Card Number: Blank line _________
d) How do you look for work and, if you have work, how do you get to work?	d) Please Explain: Blank line Blank line Blank line
11. What is your telephone number?	11. Blank line
a) If you are deaf, hard of hearing, or have a speech disability and use TTY or California Relay Service to communicate, check the appropriate box.	a) TTY (Non-voice) California Relay Service
12. What is your mailing address? (Include your city, State, and ZIP code)	12 Street: Blank line Apt.: Blank line City: Blank line State: Blank line ZIP Code: Blank line
13. Is your residence address the same as your mailing address?	13. Yes No
a) If no, enter your residence address. (Include your city, State, ZIP code and apartment number.) A residence address cannot be a P.O. Box. Please provide a street address.	a) Street: Blank line Apt.: Blank line City: Blank line State: Blank line ZIP Code: Blank line
14. If you do not live in California, what is the name of the County in which you live?	14. Blank line
15. What race or ethnic group do you identify with? Check one of the following: White Black not Hispanic Hispanic Asian American Indian/Alaskan Native Chinese Cambodian Filipino Other Pacific Islander Guamanian Asian Indian Japanese Korean Laotian Samoan Vietnamese Hawaiian I choose not to answer
16. Do you have a disability? (A disability is a physical or mental impairment that substantially limits one or more life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, or working.)	16. Yes No I choose not to answer
17. What is the highest grade of school you have completed? Check only one box. Did not complete High School High School Diploma or GED Some college or vocational school Associate of Arts Bachelor of Arts or Science Masters or Doctorate
18. Are you a Military Veteran?	18. Yes No

10.

Do you have a Driver License issued to you by a State/entity?

10.

Yes No

a)If yes, provide the name of the issuing State/entity and your Driver License number.

a)

Name of issuing State/entity: Blank line ____________

Driver License Number: Blank line _________

If no, answer questions b‑d:

b)

Do you have an Identification Card issued to you by a State/entity?

b)

YesNo

c)

If yes, provide the name of the issuing State/entity and your Identification Card number.

c)

Name of issuing State/entity: Blank line ____________

Identification Card Number: Blank line _________

d)

How do you look for work and, if you have work, how do you get to work?

d)

Please Explain:

Blank line

11.

What is your telephone number?

11.

Blank line

a)

If you are deaf, hard of hearing, or have a speech disability and use TTY or California Relay Service to communicate, check the appropriate box.

a)

TTY (Non-voice) California Relay Service

12.

What is your mailing address?
(Include your city, State, and ZIP code)

12

Street:

Blank line

Apt.:

Blank line

City:

Blank line

State:

Blank line

ZIP Code:

Blank line

13.

Is your residence address the same as your mailing address?

13.

Yes No

a)

If no, enter your residence address. (Include your city, State, ZIP code and apartment number.) A residence address cannot be a P.O. Box. Please provide a street address.

a)

Street:

Blank line

Apt.:

Blank line

City:

Blank line

State:

Blank line

ZIP Code:

Blank line

14.

If you do not live in California, what is the name of the County in which you live?

14.

Blank line

15.

What race or ethnic group do you identify with? Check one of the following:

White Black not Hispanic Hispanic Asian American Indian/Alaskan Native Chinese Cambodian Filipino Other Pacific Islander Guamanian Asian Indian Japanese Korean Laotian Samoan Vietnamese Hawaiian I choose not to answer

16.

Do you have a disability? (A disability is a physical or mental impairment that substantially limits one or more life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, or working.)

16.

Yes No I choose not to answer

17.

What is the highest grade of school you have completed? Check only one box.

Did not complete High School High School Diploma or GED Some college or vocational school Associate of Arts Bachelor of Arts or Science Masters or Doctorate

18.

Are you a Military Veteran?

18.

Yes No

DE 1101ID Rev. 6 (6-22) (INTERNET)

SAMPLE, this page for reference only

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number:

0

-

0

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0

Caption
Question	Answer
19. Provide your employment and wages information for the past 18 months. If you worked for a temporary agency, a labor contractor, an agent for actors or actresses, or an employer where wages are reported under a corporate name, your wages may have been reported under that employer name. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer. Name and mailing address of all employers you worked for in the last 18 months. Period of employment (Dates Worked). Total Wages earned for each employer in the last 18 months. How you were paid (specify hourly, weekly, monthly, annually, commission, or at piece rate). Specify if you worked full-time or part-time. How many hours you worked per week. Check the appropriate “Yes/No” box if the employer is (or is not) a school or educational institution or a public or nonprofit employer where you performed school-related work. NOTE: It is important that you report the employer name(s) and mailing address(es), period(s) of employment, and wages correctly. Failure to provide complete information will result in your benefits being delayed or denied.
a) Employer Name and Mailing Address Name: Blank line Mailing Address: Street: Blank line City: Blank line State: Blank line ZIP Code: Blank line b) Dates Worked From: Blank line To: Blank line c) Total Wages $ Blank line d) How were you paid? (e.g., weekly, monthly, etc.)? Blank line e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?Blank line g) Is this employer a school employer or a public or nonprofit employer where you performed school-related work? Yes No If yes, provide phone number: Blank line
a) Employer Name and Mailing Address Name: Blank line Mailing Address: Street: Blank line City: Blank line State: Blank line ZIP Code: Blank line b) Dates Worked From: Blank line To: Blank line c) Total Wages $ Blank line d) How were you paid? (e.g., weekly, monthly, etc.)? Blank line e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?Blank line g) Is this employer a school employer or a public or nonprofit employer where you performed school-related work? Yes No If yes, provide phone number: Blank line
a) Employer Name and Mailing Address Name: Blank line Mailing Address: Street: Blank line City: Blank line State: Blank line ZIP Code: Blank line b) Dates Worked From: Blank line To: Blank line c) Total Wages $ Blank line d) How were you paid? (e.g., weekly, monthly, etc.)? Blank line e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?Blank line g) Is this employer a school employer or a public or nonprofit employer where you performed school-related work? Yes No If yes, provide phone number: Blank line
a) Employer Name and Mailing Address Name: Blank line Mailing Address: Street: Blank line City: Blank line State: Blank line ZIP Code: Blank line b) Dates Worked From: Blank line To: Blank line c) Total Wages $ Blank line d) How were you paid? (e.g., weekly, monthly, etc.)? Blank line e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?Blank line g) Is this employer a school employer or a public or nonprofit employer where you performed school-related work? Yes No If yes, provide phone number: Blank line

19.

Provide your employment and wages information for the past 18 months. If you worked for a temporary agency, a labor contractor, an agent for actors or actresses, or an employer where wages are reported under a corporate name, your wages may have been reported under that employer name. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer.

Name and mailing address of all employers you worked for in the last 18 months.
Period of employment (Dates Worked).
Total Wages earned for each employer in the last 18 months.
How you were paid (specify hourly, weekly, monthly, annually, commission, or at piece rate).
Specify if you worked full-time or part-time.
How many hours you worked per week.
Check the appropriate “Yes/No” box if the employer is (or is not) a school or educational institution or a public or nonprofit employer where you performed school-related work.

NOTE:

It is important that you report the employer name(s) and mailing address(es), period(s) of employment, and wages correctly. Failure to provide complete information will result in your benefits being delayed or denied.

a) Employer Name and Mailing Address

Name:

Blank line

Mailing Address:

Street:

Blank line

City:

Blank line

State:

Blank line

ZIP Code:

Blank line

b) Dates Worked

From:

Blank line

To:

Blank line

c) Total Wages

$

Blank line

d) How were you paid? (e.g., weekly, monthly, etc.)?

Blank line

e)

Did you work full-time or part-time?

F/T P/T

f)

How many hours did you work per week?Blank line

g)

Is this employer a school employer or a public or nonprofit employer where you performed school-related work?

Yes No

If yes, provide phone number:

Blank line

a) Employer Name and Mailing Address

Name:

Blank line

Mailing Address:

Street:

Blank line

City:

Blank line

State:

Blank line

ZIP Code:

Blank line

b) Dates Worked

From:

Blank line

To:

Blank line

c) Total Wages

$

Blank line

d) How were you paid? (e.g., weekly, monthly, etc.)?

Blank line

e)

Did you work full-time or part-time?

F/T P/T

f)

How many hours did you work per week?Blank line

g)

Is this employer a school employer or a public or nonprofit employer where you performed school-related work?

Yes No

If yes, provide phone number:

Blank line

a) Employer Name and Mailing Address

Name:

Blank line

Mailing Address:

Street:

Blank line

City:

Blank line

State:

Blank line

ZIP Code:

Blank line

b) Dates Worked

From:

Blank line

To:

Blank line

c) Total Wages

$

Blank line

d) How were you paid? (e.g., weekly, monthly, etc.)?

Blank line

e)

Did you work full-time or part-time?

F/T P/T

f)

How many hours did you work per week?Blank line

g)

Is this employer a school employer or a public or nonprofit employer where you performed school-related work?

Yes No

If yes, provide phone number:

Blank line

a) Employer Name and Mailing Address

Name:

Blank line

Mailing Address:

Street:

Blank line

City:

Blank line

State:

Blank line

ZIP Code:

Blank line

b) Dates Worked

From:

Blank line

To:

Blank line

c) Total Wages

$

Blank line

d) How were you paid? (e.g., weekly, monthly, etc.)?

Blank line

e)

Did you work full-time or part-time?

F/T P/T

f)

How many hours did you work per week?Blank line

g)

Is this employer a school employer or a public or nonprofit employer where you performed school-related work?

Yes No

If yes, provide phone number:

Blank line

DE 1101ID Rev. 6 (6-22) (INTERNET)

SAMPLE, this page for reference only

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number:

0

-

0

-

0

Question	Answer
19. Continued a) Employer Name and Mailing Address Name: Blank line Mailing Address: Street: Blank line City: Blank line State: Blank line ZIP Code: Blank line b) Dates Worked From: Blank line To: Blank line c) Total Wages $ Blank line d) How were you paid? (e.g., weekly, monthly, etc.)? Blank line e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?Blank line g) Is this employer a school employer or a public or nonprofit employer where you performed school-related work? Yes No If yes, provide phone number: Blank line
a) Employer Name and Mailing Address Name: Blank line Mailing Address: Street: Blank line City: Blank line State: Blank line ZIP Code: Blank line b) Dates Worked From: Blank line To: Blank line c) Total Wages $ Blank line d) How were you paid? (e.g., weekly, monthly, etc.)? Blank line e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?Blank line g) Is this employer a school employer or a public or nonprofit employer where you performed school-related work? Yes No If yes, provide phone number: Blank line
20. During the past 18 months did you work for any other employers not listed in question 19?	20. Yes No If yes, list the employer information for questions 19 a–g on a separate sheet of paper. Attach the additional sheet of paper to this application.
21. If the EDD finds that you do not have sufficient wages in the Standard Base Period (SBP) to establish a valid claim, do you want to attempt to establish a claim using the Alternate Base Period (ABP)? For additional information about the Standard Base Period (SBP) and the Alternate Base Period (ABP), visit the EDD website www.edd.ca.gov	21. Yes No
22. During the past 18 months, which employer did you work for the longest?	22 Employer name: Blank line
a) What type of business was operated by the employer? (Please be specific. For example, restaurant, dry cleaning, construction, book store.)	a) Type of business: Blank line
b) How long did you work for that employer?	b) Years: Blank line Months: Blank line
c) What type of work did you do for that employer?	c) Blank line
23. What is your usual occupation?	23. Blank line
24. Is your usual work seasonal?	24. Yes No
If yes, answer questions a–c:	If yes, answer questions a‑c:
a) When does the season usually begin?	a) Blank line (mm/dd/yyyy)
b) When does the season usually end?	b) Blank line (mm/dd/yyyy)
c) What other work-related skills do you have?	c) Blank line

19.

Continued

a) Employer Name and Mailing Address

Name:

Blank line

Mailing Address:

Street:

Blank line

City:

Blank line

State:

Blank line

ZIP Code:

Blank line

b) Dates Worked

From:

Blank line

To:

Blank line

c) Total Wages

$

Blank line

d) How were you paid? (e.g., weekly, monthly, etc.)?

Blank line

e)

Did you work full-time or part-time?

F/T P/T

f)

How many hours did you work per week?Blank line

g)

Is this employer a school employer or a public or nonprofit employer where you performed school-related work?

Yes No

If yes, provide phone number:

Blank line

a) Employer Name and Mailing Address

Name:

Blank line

Mailing Address:

Street:

Blank line

City:

Blank line

State:

Blank line

ZIP Code:

Blank line

b) Dates Worked

From:

Blank line

To:

Blank line

c) Total Wages

$

Blank line

d) How were you paid? (e.g., weekly, monthly, etc.)?

Blank line

e)

Did you work full-time or part-time?

F/T P/T

f)

How many hours did you work per week?Blank line

g)

Is this employer a school employer or a public or nonprofit employer where you performed school-related work?

Yes No

If yes, provide phone number:

Blank line

20.

During the past 18 months did you work for any other employers not listed in question 19?

20.

Yes No

If yes, list the employer information for questions 19 a–g on a separate sheet of paper. Attach the additional sheet of paper to this application.

21.

If the EDD finds that you do not have sufficient wages in the Standard Base Period (SBP) to establish a valid claim, do you want to attempt to establish a claim using the Alternate Base Period (ABP)?

For additional information about the Standard Base Period (SBP) and the Alternate Base Period (ABP), visit the EDD website www.edd.ca.gov

21.

Yes No

22.

During the past 18 months, which employer did you work for the longest?

22

Employer name:

Blank line

a) What type of business was operated by the employer? (Please be specific. For example, restaurant, dry cleaning, construction, book store.)

a)

Type of business:

Blank line

b) How long did you work for that employer?

b)

Years:

Blank line

Months:

Blank line

c) What type of work did you do for that employer?

c)

Blank line

23.

What is your usual occupation?

23.

Blank line

24.

Is your usual work seasonal?

24.

Yes No

If yes, answer questions a–c:

If yes, answer questions a‑c:

a) When does the season usually begin?

a)

Blank line

(mm/dd/yyyy)

b) When does the season usually end?

b)

Blank line

(mm/dd/yyyy)

c) What other work-related skills do you have?

c)

Blank line

DE 1101ID Rev. 6 (6-22) (INTERNET)

SAMPLE, this page for reference only

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number:

0

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0

-

0

Question	Answer
Please provide information about your very last employer. This is the employer you last worked for, regardless of the length of time you worked at that job, the type of work you did for that employer, or whether or not you have been paid. If you worked for a temporary agency, a labor contractor, an agent for actors or actresses, or an employer where wages are reported under a corporate name, your wages may have been reported under that employer name. If you worked for In-Home Supportive Services (IHSS), the welfare recipient for whom you provided the in-home supportive service is your employer, not the county. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer. Reminder: To file a claim, individuals must be out of work or working less than full-time. You must provide information about the last employer you worked for as an employee. Do not include self-employment unless you have elective coverage.
25. What is the last date you actually worked for your very last employer?	25. Blank line (mm/dd/yyyy)
a)What are your gross wages for your last week of work? For Unemployment Insurance purposes, a week begins on Sunday and ends the following Saturday.	a) $ Blank line
b) What is the complete name of your very last employer?	b) Name: Blank line
c) What is the mailing address of your very last employer?	c) Mailing address: Street: Blank line City: Blank line State: Blank line ZIP Code: Blank line
d) Is the physical address of your very last employer the same as their mailing address? (A physical address cannot be a P.O. Box. Please provide a street address.)	d) Yes No
If no, what is the physical address of your very last employer?	Physical address: Street: Blank line City: Blank line State: Blank line ZIP Code: Blank line
e) What is the telephone number of your very last employer at their physical address?	e) Blank line
f) What is the name of your immediate supervisor?	f) Blank line
g) Briefly explain in your own words the reason you are no longer working for your very last employer, within the space provided. Please do not include any attachments.	g) Reason: Blank line Blank line Blank line
26. Are you (directly or indirectly) out of work with any employer (last employer or any employer in the last 18 months) due to a trade dispute, such as a strike or a lockout?	26. Yes No
If yes and a union was/is involved, answer questions a‑b:	If yes and a union was not/is not involved, answer questions c–e:
a) What is the name and telephone number of the union? Name: Blank line Phone: Blank line b) Are you going to receive strike benefits? Yes No	c) How many employees left work? Blank line____________ d) Was there a spokesperson for the employees? Yes No e) If yes, what is his/her name and telephone number? Name: Blank line Phone: Blank line

Please provide information about your very last employer. This is the employer you last worked for, regardless of the length of time you worked at that job, the type of work you did for that employer, or whether or not you have been paid.

If you worked for a temporary agency, a labor contractor, an agent for actors or actresses, or an employer where wages are reported under a corporate name, your wages may have been reported under that employer name. If you worked for In-Home Supportive Services (IHSS), the welfare recipient for whom you provided the in-home supportive service is your employer, not the county. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer.

Reminder:

To file a claim, individuals must be out of work or working less than full-time. You must provide information about the last employer you worked for as an employee. Do not include self-employment unless you have elective coverage.

25.

What is the last date you actually worked for your very last employer?

25.

Blank line

(mm/dd/yyyy)

a)What are your gross wages for your last week of work? For Unemployment Insurance purposes, a week begins on Sunday and ends the following Saturday.

a)

$

Blank line

b)

What is the complete name of your very last employer?

b)

Name:

Blank line

c)

What is the mailing address of your very last employer?

c)

Mailing address:

Street:

Blank line

City:

Blank line

State:

Blank line

ZIP Code:

Blank line

d)

Is the physical address of your very last employer the same as their mailing address? (A physical address cannot be a P.O. Box. Please provide a street address.)

d)

Yes No

If no, what is the physical address of your very last employer?

Physical address:

Street:

Blank line

City:

Blank line

State:

Blank line

ZIP Code:

Blank line

e)

What is the telephone number of your very last employer at their physical address?

e)

Blank line

f)

What is the name of your immediate supervisor?

f)

Blank line

g)

Briefly explain in your own words the reason you are no longer working for your very last employer, within the space provided. Please do not include any attachments.

g)

Reason:

Blank line

26.

Are you (directly or indirectly) out of work with any employer (last employer or any employer in the last 18 months) due to a trade dispute, such as a strike or a lockout?

26.

Yes No

If yes and a union was/is involved, answer questions a‑b:

If yes and a union was not/is not involved, answer questions c–e:

a)

What is the name and telephone number of the union?

Name:

Blank line

Phone:

Blank line

b)

Are you going to receive strike benefits?

Yes No

c)

How many employees left work? Blank line____________

d)

Was there a spokesperson for the employees?

Yes No

e)

If yes, what is his/her name and telephone number?

Name:

Blank line

Phone:

Blank line

DE 1101ID Rev. 6 (6-22) (INTERNET)

SAMPLE, this page for reference only

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number:

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0

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0

Question	Answer
27. Are you currently working for or do you expect to work for any school or educational institution or a public or nonprofit employer performing school-related work?	27. Yes No
If yes, answer questions a‑e:	If yes, answer questions a‑e:
a) Provide the following information for the school or educational institution(s) or the public or nonprofit employer(s).	a) Name: Blank line Mailing Address: Street: Blank line City: Blank line State: Blank line ZIP Code: Blank line Phone: Blank line Name: Blank line Mailing Address: Street: Blank line City: Blank line State: Blank line ZIP Code: Blank line Phone: Blank line
b) Are you a substitute teacher for Los Angeles Unified School District (LAUSD)?	b) Yes No
c) Are you currently in a recess period or off track?	c) Yes No
d) Do you have reasonable assurance to return to work after the recess period or the off-track period with any school or educational institution?	d) Yes No If yes, when? Blank line (mm/dd/yyyy)
e) What is the beginning date of your next recess or the next off track period?	e) Blank line (mm/dd/yyyy)
28. Do you expect to return to work for any former employer?	28. Yes No
29. Do you have a date to start work with any employer?	29. Yes No
If yes, answer question a:	If yes, answer question a:
a) What date will you start work?	a) Blank line (mm/dd/yyyy)
30. Are you a member of a union or non-union trade association?	30. Yes No
If yes, answer questions a–f:	If yes, answer questions a–f:
a) What is the name of your union or non-union organization?	a) Blank line
b) What is your union local number?	b) Blank line (Enter zero “0” for non-union trade association.)
c) What is the telephone number of your union or non-union trade association?	c) Blank line
d) Does your union or non-union trade association find work for you?	d) Yes No
e) Does your union or non-union trade association control your hiring?	e) Yes No
f) Are you registered with your union or non-union trade association as out of work?	f) Yes No

27.

Are you currently working for or do you expect to work for any school or educational institution or a public or nonprofit employer performing school-related work?

27.

Yes No

If yes, answer questions a‑e:

a)

Provide the following information for the school or educational institution(s) or the public or nonprofit employer(s).

a)

Name:

Blank line

Mailing Address:

Street:

Blank line

City:

Blank line

State:

Blank line

ZIP Code:

Blank line

Phone:

Blank line

Name:

Blank line

Mailing Address:

Street:

Blank line

City:

Blank line

State:

Blank line

ZIP Code:

Blank line

Phone:

Blank line

b)

Are you a substitute teacher for Los Angeles Unified School District (LAUSD)?

b)

Yes No

c)

Are you currently in a recess period or off track?

c)

Yes No

d)

Do you have reasonable assurance to return to work after the recess period or the off-track period with any school or educational institution?

d)

Yes No

If yes, when?

Blank line

(mm/dd/yyyy)

e)

What is the beginning date of your next recess or the next off track period?

e)

Blank line

(mm/dd/yyyy)

28.

Do you expect to return to work for any former employer?

28.

Yes No

29.

Do you have a date to start work with any employer?

29.

Yes No

If yes, answer question a:

a)

What date will you start work?

a)

Blank line

(mm/dd/yyyy)

30.

Are you a member of a union or non-union trade association?

30.

Yes No

If yes, answer questions a–f:

a)

What is the name of your union or non-union organization?

a)

Blank line

b)

What is your union local number?

b)

Blank line

(Enter zero “0” for non-union trade association.)

c)

What is the telephone number of your union or non-union trade association?

c)

Blank line

d)

Does your union or non-union trade association find work for you?

d)

Yes No

e)

Does your union or non-union trade association control your hiring?

e)

Yes No

f)

Are you registered with your union or non-union trade association as out of work?

f)

Yes No

DE 1101ID Rev. 6 (6-22) (INTERNET)

SAMPLE, this page for reference only

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number:

0

-

0

-

0

Question	Answer
31. Are you currently attending, or do you plan on attending school or training?	31. Yes No
If yes, answer questions a–g:	If yes, answer questions a–g:
a) What is the starting date of the school or training?	a) Blank line (mm/dd/yyyy)
b) What is the ending date of the current session?	b) Blank line (mm/dd/yyyy)
c) What is the name of the school?	c) Blank line
d) What is the telephone number of the school?	d) Phone: Blank line
e) What are the days and hours you are attending, or plan to attend, school?	e) Days and Hours: Blank line Blank line
f) Is your school or training program authorized or funded by one of the programs listed in section f? NOTE: If you are in a State Approved Apprenticeship training, you must mail your training completion certificate with your Continued Claim Form, DE 4581, for the week(s) of training.	f) Yes No If yes, check only one box. Workforce Investment Act (WIA) Employment Training Panel (ETP) Trade Adjustment Assistance (TAA) California Work Opportunity and Responsibility to Kids (CalWORKS) State Approved Apprenticeship Union or Non-union Journey Level None of the above
g) If you had a job, or were offered a job in your usual occupation, would the days and hours you attend school prevent you from working full time?	g) Yes No
32. Are you available for immediate full-time work in your usual occupation?	32. Yes No
a) If no, please explain why you are not available for full-time work.	a) Explanation: Blank line Blank line
33. Are you available for immediate part-time work in your usual occupation?	33. Yes No
a) If no, please explain why you are not available for part-time work.	a) Explanation: Blank line Blank line
34. Are you currently self-employed, or do you plan to become self-employed? (Self-employment means you have your own business or work as an independent contractor.)	34. Yes No
35. Are you now, or have you been in the last 18 months an officer of a corporation or union or the sole or major stockholder of a corporation?	35. Yes No
a) If yes, include name of organization and your title or position.	a) Name of Organization: Blank line Title/Position: Blank line
36. Did you serve as an elected public official or Governor-exempt appointee in the last 18 months?	36. Yes No

31.

Are you currently attending, or do you plan on attending school or training?

31.

Yes No

If yes, answer questions a–g:

a)

What is the starting date of the school or training?

a)

Blank line

(mm/dd/yyyy)

b)

What is the ending date of the current session?

b)

Blank line

(mm/dd/yyyy)

c)

What is the name of the school?

c)

Blank line

d)

What is the telephone number of the school?

d)

Phone:

Blank line

e)

What are the days and hours you are attending, or plan to attend, school?

e)

Days and Hours:

Blank line

f)

Is your school or training program authorized or funded by one of the programs listed in section f?

NOTE:

If you are in a State Approved Apprenticeship training, you must mail your training completion certificate with your Continued Claim Form, DE 4581, for the week(s) of training.

f)

Yes No

If yes, check only one box.

Workforce Investment Act (WIA) Employment Training Panel (ETP) Trade Adjustment Assistance (TAA) California Work Opportunity and Responsibility to Kids (CalWORKS) State Approved Apprenticeship Union or Non-union Journey Level None of the above

g)

If you had a job, or were offered a job in your usual occupation, would the days and hours you attend school prevent you from working full time?

g)

Yes No

32.

Are you available for immediate full-time work in your usual occupation?

32.

Yes No

a)

If no, please explain why you are not available for full-time work.

a)

Explanation:

Blank line

33.

Are you available for immediate part-time work in your usual occupation?

33.

Yes No

a)

If no, please explain why you are not available for part-time work.

a)

Explanation:

Blank line

34.

Are you currently self-employed, or do you plan to become self-employed? (Self-employment means you have your own business or work as an independent contractor.)

34.

Yes No

35.

Are you now, or have you been in the last 18 months an officer of a corporation or union or the sole or major stockholder of a corporation?

35.

Yes No

a)

If yes, include name of organization and your title or position.

a)

Name of Organization:

Blank line

Title/Position:

Blank line

36.

Did you serve as an elected public official or Governor-exempt appointee in the last 18 months?

36.

Yes No

DE 1101ID Rev. 6 (6-22) (INTERNET)

SAMPLE, this page for reference only

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number:

0

-

0

-

0

Question	Answer
37. Are you currently receiving a pension?	37. Yes No
If yes, answer question a:	If yes, answer question a:
a) Are you currently receiving more than one pension?	a) Yes No
If yes, proceed to question 38. If no, answer questions b–f:	If yes, proceed to question 38. If no, answer questions b–f:
b) What is the name of the pension provider?	b) Blank line
c) Is the pension based on another person's work or wages?	c) Yes No
d) Is the pension a union pension or a pension funded by more than one employer?	d) Yes No
e) What is the name of the employer(s) paying into the pension?	e) Blank line Blank line
f) Did you work for that employer in the last 18 months?	f) Yes No
38. Will you receive any additional pension(s) in the next 12 months?	38. Yes No
If yes, answer question a–b:	If yes, answer question a–b:
a) What is the name of the pension provider(s)?	a) Blank line Blank line
b) When will you receive the pension(s)?	b) Blank line (mm/dd/yyyy) Blank line (mm/dd/yyyy)
39. Are you receiving, or do you expect to receive, Workers' Compensation?	39. Yes No
If yes, answer questions a–d:	If yes, answer questions a–d:
a) Who is the insurance carrier?	a) Blank line
b) What is the insurance carrier's telephone number?	b) Phone: Blank line
c) What is the case number, if known?	c) Blank line
d) What are the dates of your claim, if known?	d) From: Blank line (mm/dd/yyyy) To: Blank line (mm/dd/yyyy)
40. Have you received or do you expect to receive, any payments from your last employer, other than your regular salary? (Example: holiday pay, vacation pay, severance pay, in-lieu-of-notice pay, etc.) Yes No If yes, provide the information in sections A–D. If you received severance pay as a lump sum, complete sections A–C (in section C, report the date the lump-sum payment was made).

37.

Are you currently receiving a pension?

37.

Yes No

If yes, answer question a:

a)

Are you currently receiving more than one pension?

a)

Yes No

If yes, proceed to question 38.

If no, answer questions b–f:

If yes, proceed to question 38.

If no, answer questions b–f:

b)

What is the name of the pension provider?

b)

Blank line

c)

Is the pension based on another person's work or wages?

c)

Yes No

d)

Is the pension a union pension or a pension funded by more than one employer?

d)

Yes No

e)

What is the name of the employer(s) paying into the pension?

e)

Blank line

f)

Did you work for that employer in the last 18 months?

f)

Yes No

38.

Will you receive any additional pension(s) in the next 12 months?

38.

Yes No

If yes, answer question a–b:

a)

What is the name of the pension provider(s)?

a)

Blank line

b)

When will you receive the pension(s)?

b)

Blank line

(mm/dd/yyyy)

Blank line

(mm/dd/yyyy)

39.

Are you receiving, or do you expect to receive, Workers' Compensation?

39.

Yes No

If yes, answer questions a–d:

a)

Who is the insurance carrier?

a)

Blank line

b)

What is the insurance carrier's telephone number?

b)

Phone:

Blank line

c)

What is the case number, if known?

c)

Blank line

d)

What are the dates of your claim, if known?

d)

From:

Blank line

(mm/dd/yyyy)

To:

Blank line

(mm/dd/yyyy)

40.

Have you received or do you expect to receive, any payments from your last employer, other than your regular salary? (Example: holiday pay, vacation pay, severance pay, in-lieu-of-notice pay, etc.)

Yes No

If yes, provide the information in sections A–D. If you received severance pay as a lump sum, complete sections A–C (in section C, report the date the lump-sum payment was made).

A. TYPE OF PAYMENT (Example: vacation pay)	B. AMOUNT OF PAYMENT (Example: ‎$600)	C. PAID FROM (Date: mm/dd/yyyy)	D. PAID TO (Date: mm/dd/yyyy)
Blank space	Blank space	Blank space	Blank space
Blank space	Blank space	Blank space	Blank space
Blank space	Blank space	Blank space	Blank space

DE 1101ID Rev. 6 (6-22) (INTERNET)

SAMPLE, this page for reference only

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number:

0

-

0

-

0

Question	Answer
41. Are you a U.S. Citizen or National?	41. YesNo
If no, answer question a:	If no, answer question a:
a) Are you registered with the United States Citizenship and Immigration Services (USCIS, formerly INS) and authorized to work in the United States?	a) YesNo
b) Were you legally entitled to work in the United States for the last 19 months?	b) YesNo
IMPORTANT: If you answered “yes” to question "a" above, you must select one of the USCIS documents listed in 41A through 41H below and provide the applicable document information.
41A. Permanent Resident Card (I-551)	41A. Permanent Resident Card (I-551)
1) Alien Registration Number (A#)	1) A# Blank line The Alien Registration Number must be 7 to 9 digits long. Enter numeric digits only.
2) Permanent Resident Card Number (CARD#) NOTE: The CARD# is on the back of the card, next to your photo, under the DOB and the EXP date.	2) Blank line The CARD# must be 13 characters long. Enter 3 alphabetic characters followed by 10 numeric digits. If your current card was issued to you before December 1997, leave this blank.
3) Expiration Date (EXP)	3) Blank line (mm/dd/yyyy)
41B. Employment Authorization Card (I-766)	41B. Employment Authorization Card (I-766)
1) Alien Registration Number (A#)	1) A# Blank line The Alien Registration Number must be 7 to 9 digits long. Enter numeric digits only.
2) Expiration Date	2) Blank line (mm/dd/yyyy)
41C. Refugee Travel Document (I-571)	41C. Refugee Travel Document (I-571)
1) Alien Registration Number (A#)	1) A# Blank line The Alien Registration Number must be 7 to 9 digits long. Enter numeric digits only.
2) Expiration Date	2) Blank line (mm/dd/yyyy)

DE 1101ID Rev. 6 (6-22) (INTERNET)

SAMPLE, this page for reference only

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number:

0

-

0

-

0

Question	Answer
41D. Arrival/Departure Record (I-94)	41D. Arrival/Departure Record (I-94)
1) Arrival/Departure Number	1) Blank line The Arrival/Departure Number must be 11 digits long. Enter numeric digits only.
2) Expiration Date	2) Blank line (mm/dd/yyyy)
41E. Re-entry Permit (I-327)	41E. Re-entry Permit (I-327)
1) Alien Registration Number (A#)	1) A# Blank line The Alien Registration Number must be 7 to 9 digits long. Enter numeric digits only.
2) Expiration Date	2) Blank line (mm/dd/yyyy)
41F. Unexpired Foreign Passport	41F. Unexpired Foreign Passport
1) Arrival/Departure Number	1) Blank line The Arrival/Departure Number must be 11 digits long. Enter numeric digits only.
2) Passport Number	2) Blank line The passport number must be 6 to 12 alphanumeric characters. It is usually found on the top right corner of the document.
3) Visa Number	3) Blank line The Visa Number must be 8 numeric digits.
4) Expiration Date	4) Blank line (mm/dd/yyyy)
41G. Arrival/Departure Record (I94) in Unexpired Foreign Passport	41G. Arrival/Departure Record (I94) in Unexpired Foreign Passport
1) Arrival/Departure Number	1) Blank line The Arrival/Departure Number must be 11 digits long. Enter numeric digits only.
2) Passport Number	2) Blank line The passport number must be 6 to 12 alphanumeric characters. It is usually found on the top right corner of the document.
3) Visa Number	3) Blank line The Visa Number must be 8 numeric digits.
4) Expiration Date	4) Blank line (mm/dd/yyyy)
41H. Other Document (not listed in Section A to G)	41H. Other Document (not listed in Section A to G)
1) Alien Registration Number (A#)	1) A# Blank line The Alien Registration Number must be 7 to 9 digits long. Enter numeric digits only.
2) Arrival/Departure Number	2) Blank line The Arrival/Departure Number must be 11 digits long. Enter numeric digits only.
3) Expiration Date	3) Blank line (mm/dd/yyyy)
4) Document Description	4) Document Description: Blank line Blank line Blank line

DE 1101ID Rev. 6 (6-22) (INTERNET)

SAMPLE, this page for reference only

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number:

0

-

0

-

0

SUPPLEMENTAL FORM FOR DISASTER UNEMPLOYMENT ASSISTANCE (DUA) – ATTACHMENT D

Please complete the following if you are unemployed or partially unemployed due to a disaster as you may be eligible for DUA benefits:

Question	Answer
1. Are you unemployed as a direct result of a recent disaster in California, such as an earthquake, flood, mudslide, wildfire, etc.?	1. YesNo
If yes:	If yes, answer questions a‑d:
a) Identify the type of disaster.	a) Blank line
b) At the time of the disaster, in which county did you reside?	b) Blank line
c) At the time of the disaster, in which county did you work?	c) Blank line
d) At the time of the disaster, was your unemployment caused by your need to travel through a disaster area?	d) YesNo
If yes:
Identify the disaster county or counties that prevent travel to your job.	Blank line Blank line Blank line
e) Check the following that best applies to you:	e) 1) An Employee who is unable to work as a direct result of the disaster. 2) An individual who was scheduled to start work for an employer, but could not because of the disaster. 3) A self-employed individual who is unable to work as a direct result of the disaster. 4) An individual who intended to begin self-employment, but could not because of the disaster. 5) An individual who became head of household as a result of the disaster.
f) If you selected item e1 or e3 above, how many hours did you work prior to the disaster?	f) Blank line
g) If you selected e3 or e4 above briefly describe how the disaster affected your ability to continue or begin your self-employment.	g) Blank line Blank line Blank line
h) What is the physical address of your business?	h) Street: Blank line City: Blank line State: Blank line ZIP Code: Blank line

1.

Are you unemployed as a direct result of a recent disaster in California, such as an earthquake, flood, mudslide, wildfire, etc.?

1.

YesNo

If yes:

If yes, answer questions a‑d:

a)

Identify the type of disaster.

a)

Blank line

b)

At the time of the disaster, in which county did you reside?

b)

Blank line

c)

At the time of the disaster, in which county did you work?

c)

Blank line

d)

At the time of the disaster, was your unemployment caused by your need to travel through a disaster area?

d)

YesNo

If yes:

Identify the disaster county or counties that prevent travel to your job.

Blank line 
Blank line 
Blank line 

e)

Check the following that best applies to you:

e)

1) An Employee who is unable to work as a direct result of the disaster.

2) An individual who was scheduled to start work for an employer, but could not because of the disaster.

3) A self-employed individual who is unable to work as a direct result of the disaster.

4) An individual who intended to begin self-employment, but could not because of the disaster.

5) An individual who became head of household as a result of the disaster.

f)

If you selected item e1 or e3 above, how many hours did you work prior to the disaster?

f)

Blank line

g)

If you selected e3 or e4 above briefly describe how the disaster affected your ability to continue or begin your self-employment.

g)

Blank line 
Blank line 
Blank line 

h)

What is the physical address of your business?

h)

Street:

Blank line

City:

Blank line

State:

Blank line

ZIP Code:

Blank line

DE 1101ID Rev. 6 (6-22) (INTERNET)

SAMPLE, this page for reference only

UNEMPLOYMENT INSURANCE APPLICATION

Social Security number:

0

-

0

-

0

DO NOT MAIL OR FAX THIS PAGE

SUBMITTING YOUR APPLICATION

Be sure to review your application thoroughly for completeness. An incomplete application may delay or prevent the filing of your claim, or cause benefits to be denied.

Submit your completed application including any applicable attachment(s) by mail or fax:

Question	Answer
By MAIL to the following address:	EDD PO Box 989738 West Sacramento, CA 95798-9738 NOTE: Extra postage is required.
By FAX to the following telephone number:	1-866-215-9159

By MAIL to the following address:

EDD
PO Box 989738
West Sacramento, CA 95798-9738

NOTE: Extra postage is required.

By FAX to the following telephone number:

1-866-215-9159

Once you submit your application, allow 10 days for processing of your claim. You will receive Unemployment Insurance (UI) claim materials by mail. If you have not received any UI claim materials after 10 days from the date you submitted your application, call one of the following toll-free telephone numbers:

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

English:

‎1-800-300-5616

Spanish: ‎

1-800-326-8937

Mandarin:

‎1-866-303-0706

TTY (Non-Voice):

‎ 1-800-815-9387

Cantonese:

‎1-800-547-3506

Vietnamese:

‎1-800-547-2058

Date Submitted:

Blank line

by Mail or Fax

KEEP THIS PAGE FOR YOUR RECORDS

DE 1101ID Rev. 6 (6-22) (INTERNET)

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SUPPLEMENTAL FORM FOR DISASTER UNEMPLOYMENT ASSISTANCE (DUA) – ATTACHMENT D

UNEMPLOYMENT INSURANCE APPLICATION

SUBMITTING YOUR APPLICATION