UI / DE 4511WS

Select a Language Value is not selected

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

Initial Claim and Payment Certification

Mail to: Special Claims Office, PO Box 419076, Rancho Cordova, CA 95741-9076

Questions? ‎1-916-464-3300

Work Sharing Employer:

Complete Section A - Employer’s Information and Certification.
Instructions for completion of this form are contained in the Guide for Work Sharing Employers, DE 8684.
This form must be issued to the employee for the first Work Sharing week within 14 calendar days after the Week Ending date shown below.
If your payroll period is other than weekly, the WEEK ENDING date must be a Saturday.

Work Sharing Employee:

Complete Section B - Employee Certification and Section C - Employee Information.
Mail completed form within 14 calendar days of the date your employer issued it.

SECTION A – EMPLOYER’S INFORMATION AND CERTIFICATION

LAST NAME:Blank space

FIRST NAME:Blank space

SOCIAL SECURITY NUMBER:Blank space

Employer’s Certification for the WEEK ENDING date: Blank line_____ /Blank line_____ /Blank line_____

Normal Weekly Wages

$Blank line__________

TOTAL Wages Paid

$Blank line__________

% of Wages Reduced Due to WS

Blank line__________ %

Normal Weekly Hours

Blank line__________

TOTAL Hours Worked

Blank line__________

% of Hours Reduced Due to WS

Blank line__________%

Yes No

During the week above, was the employee absent from work for reasons other than Work Sharing? If yes, complete a and b.

Yes No

Was the absence approved?

Yes No

Complete table below:

Date

Blank line__ /Blank line__ /Blank line__

Hours

Blank Space

Reason

Blank Space

Yes No

Did the employee refuse any work?

Enter date(s) and hour(s) used for Work Sharing reductions during this week:

Date

Blank line__ /Blank line__ /Blank line__

Hours

Blank Space

I certify the above information concerning the status of this company and the status/earnings of this employee for the purposes of participating in the Work Sharing program is true and correct. At least two, and not less than 10 percent, of the regular permanent work force, involved in the affected work unit(s), participated in the Work Sharing program, or in at least one week of a consecutive two-week period. This company will maintain employees’ health and retirement benefits under the same terms and conditions as prior to the reduction in hours and wages or to the same extent as other employees not participating in the Work Sharing plan pursuant to the California Unemployment Insurance Code (CUIC) Section, 1279.5 (c)(4)(A).

Business Name and Address:Blank space

Title:Blank space

Employer Account Number:Blank space

Printed Name of Signee:Blank space

Employer Phone Number: ( )Blank space

Employer Signature:Blank space

Date Issued to Employee: Blank line_____ /Blank line_____ /Blank line_____

Note: Date ISSUED to employee must be AFTER the week ending date.

DE 4511WS Rev. 10 (4-18) (INTRANET)

SAMPLE, this page for reference only

SECTION B – EMPLOYEE’S CERTIFICATION:

Please answer the questions regarding the WEEK ENDING date in Section A.

Yes No

Did you work for anyone other than your Work Sharing employer during the week indicated in Section A? If yes, answer a, b, and c. Note: This includes self-employment.

Other employer information:

Name:

Blank line

Address:

Blank line

City :

Blank line

State:

Blank line

ZIP Code:

Blank line

Last date worked:

Blank line___ /Blank line___ /Blank line___

Total earnings, (before deduction):

$Blank line_____

Note: Enter total earnings, whether you were paid or not.

Yes No

Are you continuing to work for this other employer? If no, state reason below:

Blank line

If you want federal income tax withheld for the week shown in Section A, mark this box:

SECTION C – EMPLOYEE INFORMATION:

This information is used to file your Work Sharing claim.

LAST NAME:Blank space

FIRST NAME:Blank space

M.I.Blank space

SOCIAL SECURITY NUMBER:Blank space

DATE OF BIRTH:Blank space

GENDER: Male Female

Yes No

Is the name on this form the same as the one that appears on your Social Security card? If no, enter the name that appears on your Social Security card.

Yes No

Last:

Blank line

First:

Blank line

M.I.:

Blank line

List any other names and/or Social Security numbers you have used:

Blank line

Mailing Address:

Blank line

Unit/Apt:

Blank line

City:

Blank line

ZIP Code:

Blank line

Phone:

Blank line

Yes No

Is your residence address the same as your mailing address? If no, enter your residence address. NOTE: A Post Office Box is not a residence address.

Street Address:

Blank line

Unit/Apt:

Blank line

City :

Blank line

State:

Blank line

ZIP Code:

Blank line

Yes No

In the past two years, have you filed either an Unemployment Insurance (UI), Work Sharing , or Disability Insurance (DI) claim in the State of California? If yes, please list the type of claim(s) filed and the date(s) when the claim(s) was filed.

Yes No

Blank line

Blank line___ /Blank line___ /Blank line___

Blank line

Blank line___ /Blank line___ /Blank line___

Yes No

In the last 18 months, did you work for an agency of the federal government or serve in the military?

Yes No

Did you work in a state other than California in the last 18 months?

Yes No

If yes, in which state(s)?

Blank line

Yes No

Have you applied for Unemployment Insurance benefits in another state during the last 12 months?

Yes No

If yes, in which state(s)?

Blank line

Yes No

Do you have a driver’s license or I.D. card? If yes, complete portion below:

Yes No

Issuing State:

Blank line

Driver License/ID number:

Blank line

DE 4511WS Rev. 10 (4-18) (INTRANET)

SAMPLE, this page for reference only

SECTION C – EMPLOYEE INFORMATION (CONTINUED)

Yes No

Are you a U.S. citizen or national? If no, complete a, b, c and d.

Yes No

Are you registered with the United States Citizenship and Immigration Services (USCIS) and authorized to work in the United States?

Select the type of United States Citizenship and Immigration Services (USCIS) document:

Permanent Resident Card (I-551)

Temporary Resident Card (I-688)

Arrival/Departure Record (I-94)

Employment Authorization Card (I-766)

Other:

Blank line

USCIS/A# number:

Blank line

Expiration Date:

Blank line

Yes No

Were you legally entitled to work in the United States for the last 19 months?

Yes No

Are you receiving, or will you receive a pension in the next year other than Social Security, which is based on your own work and wages? If yes, complete a ,b, c and d.

Who pays the pension check to you?

Blank line

How are you receiving your payments?

Monthly

Annually

Single Installment

Yes No

Did you pay into your pension or retirement?

Yes No Unsure

Did an employer you worked for in the last 18 months pay into your pension fund?

If yes, what is the name of the employer?

Blank line

Pension Amount:

Blank line

10.

List the employers you worked for in the last 18 months, include earnings of how often you were paid and dates worked.

Employer Name	Earnings	Payment Cycle	Dates Worked
___________Blank Line	$ ___________Blank space	___________Blank Line	Blank line__ /Blank line__ /Blank line__ to Blank line__ /Blank line__ /Blank line__
___________Blank Line	$ ___________Blank space	___________Blank Line	Blank line__ /Blank line__ /Blank line__ to Blank line__ /Blank line__ /Blank line__
___________Blank Line	$ ___________Blank space	___________Blank Line	Blank line__ /Blank line__ /Blank line__ to Blank line__ /Blank line__ /Blank line__

11.

Which employer did you work for the longest?

Blank line

What type of business does that employer do?

Blank line

What type of work did you do for this employer?

Blank line

How long did you work for this employer?

Blank line

12.

Yes No

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

13.

Yes No

Are you receiving or do you expect to receive workers’ compensation? If yes, fill in information below.

11.

Name of Insurance Carrier:

Blank line

Case Number:

Blank line

11.

Amount of worker’s compensation payment:

Blank line

14.

Written language preference:

English Spanish

15.

Spoken language preference:

English Spanish

Other

Blank line

The following questions are OPTIONAL:

What race or ethnic group do you identify with?

Blank line

I choose not to answer

Do you have a disability?

Yes No I choose not to answer

I do hereby claim benefits. I am a Work Sharing employee working reduced hours. The information provided above is true and correct to the best of my knowledge and belief. Pertaining to Question 8, citizenship status, I declare under PENALTY OF PERJURY, under the laws of the State of California, that my answer is true and correct. I understand the law provides a fine and/or imprisonment for making false statements or withholding facts to fraudulently receive Unemployment Insurance benefits.

SIGN HERE Employee Signature:Blank space

Date Signed:Blank space

Note: Date signed must be On or After the date issued by the employer.

DE 4511WS Rev. 10 (4-18) (INTRANET)

Your session has timed out.

Click here to access the application.

UI / DE 4511WS

Initial Claim and Payment Certification

SECTION A – EMPLOYER’S INFORMATION AND CERTIFICATION

SECTION B – EMPLOYEE’S CERTIFICATION:

SECTION C – EMPLOYEE INFORMATION:

SECTION C – EMPLOYEE INFORMATION (CONTINUED)