SAMPLE, this page for reference only

BENEFIT CHECK COPY INSTRUCTIONS

Enclosed is a copy of the Unemployment Insurance (UI) or Disability Insurance (DI) benefit check(s) you requested.

If you requested a copy of the benefit check to verify the endorsement signature, please follow the instructions below.

1. Review the endorsement signature on the copy of the check.
2. If you determine that the endorsement signature is yours or the money was used on your behalf, no further action is necessary.
3. If you believe the endorsed signature is not yours or was not authorized by you and the money was not used on your behalf, you will need to request a Declaration Under Penalty of Perjury Forged Endorsement form.

For UI checks, to request a Declaration Under Penalty of Perjury Forged Endorsement Unemployment Insurance (UI) Check (DE 817D) form, contact the EDD using the information below.

For DI checks, to request a Declaration of Forged Endorsement of Disability Insurance Check, (DE 817DIS) form, contact the EDD using the information below.

DE 817A Rev. 5 (4-13) (INTRANET)