Fillable APPEAL FORM If you disagree with the Notice (California)

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APPEAL FORM If you disagree with the Notice (California)

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EDD Telephone Numbers:
E
NGLISH 1-800-300-5616
S
PANISH 1-800-326-8937
C
ANTONESE 1-800-547-3506
M
ANDARIN 1-866-303-0706
V
IETNAMESE 1-800-547-2058
T
TY (non-voice) 1-800 815-9387
website: www.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.
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 I 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: Social Security Number: - -
Do you need a translator? Yes No If yes, what language/dialect?
Appellant Address: Telephone No.: ( ) -
Street No., Apt. No., or P.O. Box
Fax No.: ( ) -
City State ZIP Code
E-mail Address: Cell Phone No.: ( ) -
I authorize the CUIAB to send confidential information regarding my appeal to the e-mail address listed above.
I authorize the CUIAB to send confidential information regarding my appeal by text message or voice mail to the
cell phone number listed above.
Complete this section for employer appeals only
Employer Account Number: Agent Name (if applicable):
Agent Address:
Street No., Apt. No., or P.O. Box City State ZIP Code
SECTION II 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 because
Signature of
Appellant or Agent: Date:
DE 1000M/H Rev. 8 (6-15) (INTERNET) CU
- Hmong version on other side -
Page 1 of 2
DE 1000M/H Rev. 8 (6-15) (INTERNET) MIC 38/CU
EDD Tsu Xovtooj:
A
AS KIV 1-800-300-5616
MEV 1-800-326-8937
SUAV (CANTONESE) 1-800-547-3506
SUAV (MANDARIN) 1-866-303-0706
NYAB LAJ 1-800-547-2058
TTY (tsis hais lus) 1-800 815-9387
website: www.edd.ca.gov
DAIM NTAWV ROV HAIS DUA
Yoj koj tsis pom zoo raws li Daim Ntawv Qhia Qhov Tsom Xam thiab/los sis lub Tuam Tsev EDD kev Txiav Txim Siab yuav qhov
Kev Tsom Xam ntawd lawm, muab koj daim ntawv no qhia cov ntsiab lus kom meej tias yog vim li cas koj thiaj tsis pom zoo xa
mus hais dua txog lawv qhov kev txiav txim siab ntawd tau ntawm xeev Kaslisfausnias Pawg Thawj Tswj lub Tuam Tsev Saib
Cov Neeg Poob
Hauj Lwm (CUIAB). Koj yuav tsum kes npe rau daim ntawv no es muab xa rov qab mus rau EDD ntawv qhov
chaw nyob uas muaj nyob rau ntawm daim ntawv tshab xo tias koj yuav rov qab mus hais dua ntawd. KOJ MUAJ 30 HNUB PIB
TXIJ LI HNUB KOJ XA DAIM NTAWV TSHAB XO TXOG QHOV YUAV HAIS DUA NO MUS UA KOM TIAV DAIM NTAWV
TEEM CAIJ ROV MUS HAIS DUA. Yog koj mus hais tom qab 30 hnub ntawd lawm, koj yuav tsum qhia seb qhov qeeb ntawd
yog vim licas. Tus Thawj Txiav Plaub (ALJ) mam soj ntsuam saib qhov koj lig ntawd puas tsim nyog. Yog tus ALJ xam pom tias
qhov koj tuaj hais lig ntawd tsis muaj pov thawj txaus, ces yuav muab qhov koj thov hais dua no lawb mus.
COV THOV NYIAJ: Lub caij tseem nyob tos qhov yuav Rov Mus Hais Dua ntawd, koj yuav tsum niaj hnub qhia koj cov nyiaj
raws caij nyoog mus tsis txhob pub tu ncua. Yog xam pom tias koj yuav tsum tau nyiaj pab, koj yuav tau nyiaj rau cov sij
hawm uas koj niaj hnub mus hais qhia ntawd thiab tseem yuav tau kev pab lwm yam uas koj tsim nyog tau txais ntxiv thiab.
CIM CIA: Cov thov Nyiaj Poob Hauj Lwm Vim Raug Kev Puam Tsuaj muaj 60 hnub ua daim ntawv Rov Mus Hais Dua. Cov Tsev
Hauj Lwm uas rov mus hais dua raws li Daim Ntawv Tsom Xam los yog Soj Ntsuam, DE 3807, muaj 30 hnub ua daim ntawv rov
mus hais dua.
NQI 1. TUS YUAV ROV MUS HAIS DU
A
COV LUS QHIA UA DAIM NTAWV: Tus yuav rov mus hais dua (tus ua hauj lwm los yog tus muaj tsev hauj lwm uas yuav rov
mus hais dua) yuav tsum teb cov lus muaj nyob hauv nov txhua lo, los yog tus tau lus tso cai kom ua tus sawv cev tus neeg yuav
rov qab mus hais dua. Tus yuav rov mus hais dua lo yog tus sawv nws cev yuav tsum kes nws lub npe. Thov siv cov KUA MEM
DUB ua daim ntawv no.
Tus Yuav Rov Mus Hais Dua Lub Npe: Tus Leb Social Security: - -
Koj puas xa kom muaj tus txhais lus? Muaj Tsis muaj Yog muaj no, xav tau hom lus twg?
Tus yuav rov mus hais dua chaw nyob: Tus Xovtooj: ( ) -
Leb tsev, txoj kev, chav nyob, los yog chaw xa ntawv “P.O. Box”
Xovtooj Nquam Ntawv: ( ) -
Lub Nroog Xeev tus leb “ZIP Code”
Tus E-mail: Xovtooj ntawm tes: ( ) -
Kuv tso cai rau CUIAB xa kuv cov ntawv hais txog tej kuv yuav rov qab mus hais dua mus rau cov “e-mail” saum no.
Kuv tso cai rau CUIAB xa kuv cov ntawv hais txog tej kuv yuav rov qab mus hais dua mus rau cov xovtooj sau ntawv los
yog cov xovtooj kaw lus ntawm cov xov tooj muaj nyob saum no.
Nov yog tus tswv hauj lwm ua nkaus xwb
Tus Leb Cim Tsev Hauj Lwm: __________ Tus Sawv Cev Npe (yog muaj): ___________________________
Tus Sav Cev Chaw Nyob: _______ ___
Tus leb tsev, txoj kev, chav tsev los yog chaw xa ntawv “P.O. Box” Nroog Xeev Tus leb “ZIP Code”
NQI. II TUS YUAV ROV MUS HAIS DUA COV LUS
COV LUS QHIA UA DAIM NTAWV : Piav cov niam tswv yim uas koj yuav rov mus hais ntawd tias yog vim li cas koj thiaj tsis
pom zoo raws li qhov lawv txiav txim ntawd. Yog lawv kom koj muaj ntau yam ntxiv, koj yuav tau lo ib co ntawv uas yuav pab tau
koj ntxiv rau thiab sau koj tus leb Social rau txhua daim hu tib si.
Kuv tsis pom zoo qhov nej xam pom raws li tsab ntawv tshab xo hnub tim _____ __vim tias
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Kes npe
Tus Rov Tuaj Hais Dua los yog Tus Sawv Cev: Hnub tim: __________
- English version on other side -
Page 2 of 2
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APPEAL FORM If you disagree with the Notice (California)

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Completed 11 May 2021

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