UI / DE 1101ER

SAMPLE, this page for reference only.

Employment Development Department
PO Box 989059
West Sacramento, CA 95798-9059

NOTICE OF UNEMPLOYMENT INSURANCE CLAIM FILED

‎Name
‎Address
City, State ZIP
Mail Date:
MM/DD/YYYY
Corrected Mail Date:
MM/DD/YYYY
New Claim:
0000 00000000
Additional Claim:
0000

ACTION REQUIRED

  1. Gather the necessary facts for this claim.
  2. Complete the reverse side of this form.
  3. Mail this response within 10 calendar days of the above mail date to the address shown above.
Failure to respond within 10 calendar days may result in an increased employment tax rate and employer penalties.
You received this notice because the claimant shown below filed a claim for unemployment insurance benefits and listed you as his/her most recent employer. The claimant provided the following information:
Claimant's Name:
XXXX XXXX
Effective Date of Claim:
MM/DD/YYYY
Reason for Separation:
XXXX
Social Security Number:
XXX-XX-0000
Last Date Worked:
MM/DD/YYYY

REPORTING FACTS

The law requires you to submit any facts in your possession which may affect a claimant's eligibility for benefits. These facts will be used in determining the claimant's eligibility for benefits. Provide information to the Employment Development Department (EDD) if this claimant:
  • Voluntarily quit, was discharged, or fired.
  • Left work because of a strike or trade dispute.
  • Is working, whether full-time or part-time.
  • Has refused employment.
  • Performed services as a sports or athletic participant.
  • Is not legally entitled to work in the US
  • Is a school employee and has a contract for or reasonable assurance of returning to work following a recess.
  • Is not able to work, available for work, or seeking work.
  • Is receiving a pension.

TIME LIMITS FOR REPLYING

Submit facts in writing to the EDD in the envelope provided within 10 calendar days from the above mail date to be considered timely. If your mailing is late, explain your reason for delay as the time limit may be extended only for good cause. If you respond timely, you will be issued a written notice of the EDD's determination concerning the claimant's eligibility which will provide you with appeal rights. In addition, if facts are submitted regarding a quit or discharge, you will be issued a ruling as to whether your reserve account will be subject to charges if you are a tax-rated employer. If you respond untimely, the EDD will still consider the facts provided by you. However, you may not be issued a written notice of the EDD's determination, including appeal rights, unless the EDD determines that you had good cause for the delay. If you acquire facts that could not have reasonably been known within this 10-day response period, provide these facts to the EDD within 10 calendar days of acquiring them.

ELIGIBILITY DETERMINATION INTERVIEW

It may be necessary to contact you by phone or letter for additional eligibility information. If no response is received, the EDD is required to make an eligibility determination based on available information.

EMPLOYER REQUIREMENTS AND POTENTIAL PENALTIES

The California Unemployment Insurance Code (CUIC) provides penalties for employers who:

  • Willfully make false statements or representations, or willfully fail to report a material fact in connection with a separation issue or a written statement concerning reasonable assurance of a claimant's reemployment (CUIC Section 1142).
  • Willfully make a false statement or knowingly fail to disclose a material fact to obtain, increase, reduce, or defeat any payment of benefits (CUIC Section 2101).
  • Fail to respond timely or adequately to requests of the Department for information and are at fault for causing overpayment of benefits (CUIC Section 803(d), 821(c), and 1026.1).
For more information on fraud and penalties, visit www.edd.ca.gov and select the Fraud and Penalties link.
DE 1101ER Rev. 8 (10-17) (INTERNET)

SAMPLE, this page for reference only.

Did you know? You can electronically receive and respond to future requests for separation information by using the State Information Data Exchange System (SIDES). To get started, visit the SIDES web page at www.edd.ca.gov/SIDES

Reporting Facts:

Claimant's Social Security Number (from your payroll records):
‎X
 
X
 
‎X
 
‎-
X
 
X
 
-
0
 
‎0
 
‎0
 
‎0
 
Claimant's Job Title:
XXXX
Rate of Pay $:
00.00
per:
XXXX
Last Date Physically Worked:
XXXX
Length of Employment:
XXXX
Date of Separation (if different from last date physically worked):
MM/DD/YYYY
Name of immediate supervisor:
XXXX

Reason for Separation (Check only one):

Who did the claimant notify of the quit?/Who terminated the claimant?
XXXX
Person's Job Title:
XXXX
*Do not submit this form to the EDD if the claimant was laid off due to lack of work and no other eligibility issues exist.
Provide a brief explanation of the final incident that resulted in the claimant's separation:
XXXX
Blank line

Compensation:

If you checked the box, please provide the following information:
Amount $:
00.00
Type of Payment:
XXXX
for period from
MM/DD/YYYY
through
MM/DD/YYYY

Employer and Contact Information:

Employer Name:
XXXX
Employer Payroll Tax Account Number:
0
0
0
-
0
0
0
0
-
0
By signing below, I certify that I am an authorized representative and the information provided in response to this notice is true and correct. I understand that any false statement, false representation, or failure to report a material fact may result in employer penalties and charges.
Print Name:
XXXX
Phone No:
‎000
-
‎000
-
‎0000
Ext:
000
Signature:
Blank line
Title:
XXXX
Date:
MM/DD/YYYY
DE 1101ER Rev. 8 (10-17) (INTERNET)