UI / DE 4365MA

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 
 
EDD Telephone Numbers
English:
1-800-300-5616
Spanish:
1-800-326-8937
Cantonese:
1-800-547-3506
Mandarin:
1-866-303-0706
Vietnamese:
1-800-547-2058
TTY(Non-voice):
1-800-815-9387
EDD Internet Site:
edd.ca.gov
For Office Use Only:

REQUEST FOR ELIGIBILITY INFORMATION

There is a question about your eligibility for Unemployment Insurance (UI) or Pandemic Unemployment Assistance benefits beginning mm/dd/yyyy. This request is being sent to gather information from you to help the Employment Development Department (EDD) make a decision regarding your eligibility. The review of all available information may take up to three weeks to complete.

You must complete, sign, and mail this form along with your required supporting documentation to the EDD address listed above by mm/dd/yyyy.

Failure to provide verifiable information may result in your disqualification from receiving future UI benefits and you may be required to pay back the UI benefits you already received. You may also be assessed additional penalties as provided for under the law.

You must provide the following information and documentation:
  1. Your current mailing address:
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  2. Your current residential address:
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  3. How long you have lived at this address:
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  4. Provide all addresses you have used during the past three years. (Begin with your most recent mailing and/or residential address, include the full street address or Post Office Box, city, state, and ZIP code.) If you need more space, you may write on the back of this form.
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You must provide proof of your residence by submitting a clear and unaltered copy (or original) of at least one of the following documents:

  •  Utility bill (electricity, gas, garbage, water, or sewer), cable TV bill, phone bill, property tax bill.
  • Bank statement or mortgage statement.
  • Current and complete rental/lease agreement.
  • Registration verification as a renter/authorized user of a Post Office Box or a Private Mail Box.

SIGN AND DATE THE BACK OF THIS FORM

DE 4365MA (1-21) (INTERNET)

SAMPLE, this page for reference only

Sign and date this form and mail it with the required documentation to the EDD address provided above. 

I understand the law provides penalties if I make false statements or withhold facts to obtain benefits. I declare under penalty of perjury that the information I am providing is true and correct.
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PRINT YOUR NAME
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SIGNATURE
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DATE

DE 4365MA (1-21) (INTERNET)