UI / DE 1000M

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
website:
edd.ca.gov

APPEAL FORM

If you disagree with the Notice of Determination(s) and/or Determination(s)/Rulings by the EDD, you may appeal the decision(s) to the California Unemployment Insurance Appeals Board (CUIAB) by completing this form and explaining why you disagree. You must sign the form and return it to the EDD at the office address listed on the notice that you are appealing. YOU HAVE 30 DAYS FROM THE MAIL DATE OF THE NOTICE TO FILE A TIMELY APPEAL. If you appeal after the 30 day period, you must include the reason for the delay. The administrative law judge (ALJ) will determine whether you had good cause for the delay. If the ALJ determines you did not have good cause to submit your appeal late, your appeal will be dismissed. Learn more about appealing a decision at edd.ca.gov/UI_Appeals
CLAIMANTS: While your appeal is pending, you must continue to certify for benefits. If you are found eligible, you can be paid only for periods for which you have certified and have met all other eligibility requirements.
NOTE: Claimants for Disaster Unemployment Assistance (DUA) have 60 days to file an appeal. Employers appealing the Notice of Determination or Assessment (DE 3807), have 30 days to file an appeal.
SECTION one
APPELLANT INFORMATION
INSTRUCTIONS: The following information must be provided by the Appellant (the claimant or employer who is appealing a notice), or by the authorized agent or representative of the Appellant. The signature of the Appellant or agent is required. Please use BLACK INK when filling out this form.
Claimant Name:
Blank line
Social Security Number:
Blank line
Do you need a translator?
If yes, what language/dialect?
Blank line
Appellant's Mailing Address:
Blank line 
Street No, Apt No, or PO-Box
 
Telephone No:
Blank line
 
Blank line 
City
Blank line 
State
Blank line 
ZIP Code
 
Fax No:
Blank line
Email Address:
Blank line
 
Cell Phone No:
Blank line
Complete this section for employer appeals only
Employer Account Number:
Blank line
Agent Name (if applicable):
Blank line
Agent Address:
Blank line 
Street No, Apt No, or PO-Box
Blank line 
City
Blank line 
State
Blank line 
ZIP Code
SECTION two
APPELLANT STATEMENT
INSTRUCTIONS: Explain the reason for your appeal and why you disagree with the decision(s). If required, attach additional pages to this form and write your name and Social Security number on each page.
I disagree with the determination in the notice dated Blank line because
Blank Box
Signature of Appellant or Agent:
Blank line 
Date:
Blank line 

DE 1000M Rev. 9 (3-26)