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SAMPLE, this page for reference only
You have applied for an Unemployment Insurance (UI) or Disability Insurance (DI) claim and requested wages to be added to your claim award. The Employment Development Department (EDD) will attempt to add wages based on information that is obtained from your employer. If no information is received from your employer, then EDD will review wage information you provide and add wages, as appropriate.
Please provide proof of wages paid by , and complete sections A through H below. Attach copies of your W-2 and/or check stubs on an 8 ½ x 11 inch sheet of paper that include the amount of earnings and the dates worked. Every sheet submitted to EDD must include your name and social security number. This form MUST be completed and returned with your proof of earnings to the EDD address, or fax to the number shown above by .
For additional information, review the information on the back of this form or contact us at the number listed above.
I understand the law provides penalties if I make false statements or withhold facts to receive benefits. I understand wage determinations based on the affidavit are not final: that wage determinations are subject to correction upon the receipt of wage information from the employer, that benefit payments may have to be adjusted on the basis of the information from the employer, and that any amount overpaid may have to be repaid or offset against future benefits. I declare the information provided is true and correct to the best of my knowledge. Your signature is required. Your benefits may be delayed or denied if this form is not signed.
Signature of Claimant
Date
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 23A Rev. 4 (3-22) (INTERNET)
You have applied for an Unemployment Insurance or a Disability Insurance claim and requested wages to be added to your claim award.
If you fail to respond to this form within 10 days, it may delay or prevent paying benefits on your claim. If you fail to sign this form, the form will be returned and this may delay or prevent paying benefits on your claim.
Please do not mail original documents. All documents submitted should be copies provided on 8 ½ x 11 inch paper and should include your full name and your complete social security number.
All wage information will be carefully reviewed and audited by a quarterly wage report. Any discrepancies between the information provided by you and the information provided by your employer may affect the weekly benefit amount of the claim. An overpayment and penalty will be assessed if it is discovered that a false statement or intentional misreporting of wages has occurred.
The base period consists of four calendar quarters of three months each. When a base period begins and which calendar quarters are used depends on whether the claim is for Unemployment Insurance or for Disability Insurance and on what date the claim begins.
Disability Insurance claims have a base period which covers a 12-month period of time and is divided into four consecutive quarters of three months each. The wages an individual was paid approximately 5 to 18 months before the Disability Insurance claim begins are included in the base period (and they must have been subject to the State Disability Insurance (SDI) tax).
Unemployment Insurance claims have a standard base period and the option of an alternate base period only when using the standard base period results in a claim that is not monetarily valid.
The standard base period is the FIRST FOUR of the last five completed calendar quarters prior to the beginning date of the claim.
The alternate base period is the LAST FOUR completed calendar quarters prior to the beginning date of the claim.