UI / DE 1181

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

AUTHORIZATION FOR RELEASE OF UNEMPLOYMENT INSURANCE (UI) RECORDS FOR RETIRED ANNUITANT

To: Employment Development Department
Orange County Primary Call Center
P.O. Box 5007
Buena Park, CA 90622
I,
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PRINT YOUR NAME
,

authorize the Employment Development Department (EDD) to release my Unemployment Insurance (UI) information for purposes related to Government Code section 21224 [Retired Annuitant return to work prohibition for a CalPERS employer if UI benefits collected within the last 12 months] to:

Date:
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MONTH/DAY/YEAR
Signature:
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RETIRED ANNUITANT SIGNATURE
(This Authorization shall remain in effect for 12 months from the date signed.)
Social Security Number:
XXX- XX- Blank space
Date of Appointment:
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Failure to sign this consent does not preclude the appointing entity authority from obtaining this information from the EDD after you are hired, pursuant to California Unemployment Insurance Code (CUIC) section 322.

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APPOINTING AGENCY REPRESENTATIVE SIGNATURE
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PRINT NAME
 

TO BE COMPLETED BY EDD

Were UI benefits paid to the above individual in the last 12 months?
If yes, date last paid:
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For week ending:
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If yes, base period employer names:Blank Space
STAMP
DATE RECEIVED BY EDDBlank space
CONFIDENTIALITY NOTICE: This notice is for the sole use of the intended recipients. It contains confidential or sensitive information. Under Penal Code‎ 502 and Civil Code ‎1798.53 , any unauthorized review, use, disclosure, or distribution of the content of this document is prohibited and subject to criminal penalties/fines. If you are not the intended recipient, please contact the EDD.
DE 1181 Rev. 3 (7-21) (INTERNET)