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Employment
EDD
Development
Department
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_________________
NOTICE OF REDUCED EARNINGS
LAST NAME FIRST NAME SOCIAL SECURITY NUMBER
NOTE: Issue a DE 2063 only for the seven-consecutive-day period corresponding to your payroll week. If you pay
your workers less often than once each seven days, you must issue a DE 2063 for each calendar week
(Sunday through Saturday) of partial unemployment.
PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS.
EDD USE ONLY
Interviewer’s Initial
AC
EMPLOYER’S STATEMENT FOR THE PAYROLL WEEKENDING DATE: (MM/DD/YY)
1.
Gross earnings (before deductions) were (if there were no earnings, enter Ø)....................................................................
$
2. Did this employee report for all work that was available during this payroll week?
............................................................... Yes No
(a) If the answer is “NO” give date(s)
(b) REASON:
3. Why is this employee not working full-time? (Check one)
Lay off due to lack of work (includes reduction in hours) Discharged Voluntary Quit
4. Enter the last date this employee performed any work in your employment either on or prior to the payroll weekending date shown above:
(MM/DD/YY)
EMPLOYER CERTIFICATION: I CERTIFY that the amount in Item 1 represents reduced earnings in a week of less than full-time work because
of lack of work except as shown in Item 2.
ENTER
YOUR
Company Name Phone Number
(
)
Address City Zip Code
Employer Signature
Employer Account Number
DATE ISSUED TO EMPLOYEE:
(MM/DD/YY)
ISSUE THIS FORM IMMEDIATELY AFTER PAYROLL WEEKENDING DATE SHOWN ABOVE
CLAIMANT:
You must complete this section. These questions and your answers are for the payroll weekending date(s) shown on the top of this form.
A. Was there any reason other than lack of work why you couldn’t have worked full-time each regular workday that week?
Yes No
(1) If yes, give reason, dates and time you could not work:
B. Did you work for anyone other than your regular employer on any day in that week? (This includes self-employment.)
Yes No
(1) What is the employer’s name?
Address:
(2) How much did you earn before deductions from that employer whether you were paid or not? .................................
$
(3) Dates worked to . Reason no longer working:
C. Are you receiving a pension, other than Social Security?
.................................................................................................
Yes No
(1) If yes, has there been a change in the amount since you last reported it?
...................................................................
Yes No
(2) If there has been a change, enter the new gross amount. .......................................................................................... $
Explain the reason for the change:
D. Did you have a change of address or telephone number in that week? ...............................................................................
Yes No
(1) If yes, please provide the information in the space below.
E.
If you want federal income tax withheld for that week, mark this block
CLAIMANT CERTIFICATION: I understand the questions on this form. I know the law provides penalties if I make false statements or
withhold facts to receive benefits; my answers are true and correct. I declare under penalty of perjury that I am a U.S. citizen or national, or
a non-citizen in satisfactory immigration status and permitted to work by the U.S. Citizenship and Immigration Services.
Your Signature is Required Telephone Number
( )
Address City Zip Code
NOTE: THIS CLAIM IS TIMELY ONLY BY CONTACTING THE EMPLOYMENT DEVELOPMENT DEPARTMENT WITHIN 28 DAYS AFTER ISSUED TO
YOU. EXCEPTION: IF YOU KNOW THAT YOU WILL BE TOTALLY UNEMPLOYED IN EXCESS OF TWO CONSECUTIVE WEEKS, CONTACT
EDD IMM
EDIATELY.
Versión en esp
añol en el dorso
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DE 2063 Rev. 26 (8-10) (INTERNET) CU
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Employment
EDD
Development
Department
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I I
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_________________
NOTICE OF REDUCED EARNINGS
LAST NAME FIRST NAME SOCIAL SECURITY NUMBER
NOTE
:
Issue a DE 2063 only for the seven-consecutive-day period corresponding to your payroll week. If you pay
your workers less often than once each seven days, you must issue a DE 2063 for each calendar week
(Sunday through Saturday) of partial unemployment.
PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS.
EDD USE ONLY
Interviewer’s Initial
AC
EMPLOYER’S STATEMENT FOR THE PAYROLL WEEKENDING DATE: (MM/DD/YY)
1.
Gross earnings (before deductions) were (if there were no earnings, enter Ø)
$
2. Did this employee report for all work that was available during this payroll week?
Yes No
(a) If the answer is “NO” give date(s)
(b) REASON:
3.
Why is this employee not workin
g
full-time? (Check one)
Lay off due to lack of work (includes reduction in hours) Discharged Voluntary Quit
4.
Enter the last date this employee performed any work in your employment either on or prior to the payroll weekendin
g
date shown above:
(MM/DD/YY)
EMPLOYER CERTIFICATION: I CERTIFY that the amount in Item 1 represents reduced earnings in a week of less than full-time work because
of lack of work except as shown in Item 2.
ENTER
YOUR
Company Name Phone Number
(
)
Address City Zip Code
Employer Signature
Employer Acco
unt Number
DATE ISSUED TO EMPLOYEE:
(MM/DD
/YY)
ISSUE THIS FORM IMMEDIATELY AFTER PAYROLL WEEKENDING DAT
E SHOWN A
BOVE
SOLICITANTE:
Usted deberá completar esta sección. Estas preguntas y sus respuestas son para la semana de pago que termina en la fecha indicada en este formulario.
A. ¿Había otra razón, además de la falta de trabajo, por la cual Ud. no podría haber trabajado horario completo
cada día normal de trabajo en esa semana? No
(1) Si contesta que “sí,” proporcione la razón, las fechas y las horas en que no podía trabajar
B. ¿Trabajó Ud. para alguien que no es su empleador normal, cualquier día de esa semana?
(Esto incluye trabajos independientes o en su propio negocio)
No
(1) ¿Cual es el nombre de ese empleador?
Dirección:
(2) ¿Cuánto ganó, Ud. antes de deducciones, con ese empleador, aunque toda
vía no le haya pagado? $
(3) Fechas en que Ud. trabajó: del al . Razón porque Ud. no siguió trabajando
C. ¿Está Ud. recibiendo una pensión que no sea del Seguro Social?
No
(1) Si contesta que “si,” ¿ha habido un cambio en la cantidad que Ud. recibe desde la última vez que la reportó? No
(2) Si la cantidad ha cambiado, favor
de escribir la nueva cantidad bruta. $
Explique la razón por el cambio:
D. ¿Cambió Ud. de domicilio o de número de teléfono en esa semana?
No
(1) Si contesta “sí”, favor de proporcionar la información en el espacio a continuación.
E.
Si usted desea que se retengan impuestos federales por ésa semana, marque esta casilla
CERTIFICACIÓN DEL SOLICITANTE: Entiendo las preguntas que contiene este formulario. Se que la ley establece sanciones si hago declaraciones falsas o
retengo información para recibir beneficios. Mis respuestas son verdaderas y correctas. Declaro bajo pena de perjurio que soy ciudadano o nacional de los Estados
Unidos, o soy un(a) extranjero(a) con situación migratoria satisfactoria y con permiso del Servicio de Ciudadanía e Inmigración de los Estados Unidos para trabajar.
Se Requiere su Firma Número de Teléfono
( )
Dirección Ciudad Código Postal
NOTA: ESTA SOLICITUD DE BENEFICIOS SERÁ CONSIDERADA A TIEMPO SOLAMENTE CUANDO USTED SE COMUNICA CON EL
DEPARTAMENTO DEL DESARROLLO DEL EMPLEO DENTRO DE 28 DÍAS DESPUÉS DE LA FECHA EN QUE SE LE EMITIÓ A USTED.
EXCEPCIÓN: SI UD. TIENE CONOCIMIENTO QUE ESTARÁ TOTALMENTE DESEMPLEADO(A) POR MÁS DE DOS SEMANAS
CONSECUTIVAS, COMUNÍQUESE INMEDIATAMENTE EL EDD.
English version on other side - -
DE 2063 Rev. 26 (8-10) (INTERNET) CU/MIC 38
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