Fill - Free fillable UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) (California) PDF form

UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee)

FILING INSTRUCTIONS

Complete this application including any applicable attachment(s). Print or type the information. Use blue or black ink only.

Answer all questions on each page. Review your application thoroughly for completeness. An incomplete application may delay

or prevent the ling of your claim, or cause benets to be denied. If the Employment Development Department (EDD) needs to

verify any of the information you provide while ling a claim, you will receive additional forms by mail and will be asked to provide

additional information and/or documentation.

APPLICATION QUESTIONS

The answers you give to the questions on this application must be true and correct. You may be subject to penalties if you make a

false statement or withhold information.

1. Did you work in a state other than California during the

last 18 months?

AND / OR

Did you work in Canada during the last 18 months?

1. Yes No If yes, check the applicable box(es) below:

State(s) Outside California, specify state(s):

Canada

2. What is your Social Security number as given to you

by the Social Security Administration?

a) If the EDD assigned you an EDD Client Number

(ECN), please provide the ECN here. (An ECN is a

9-digit number beginning with 999 or 990.)

2.

a)

2A. List any other Social Security numbers you have used. 2A.

3. What is your full name? 3. Last

First

Middle Initial

4. Is this the name that appears on your Social Security

card?

a) If no, provide the name that appears on your

Social Security card.

4. Yes No

a) Last

First

Middle Initial

5. List any other names you have used. 5.

6. What is your birth date? 6. (mm/dd/yyyy)

7. What is your gender?

7. Male Female

8. Would you prefer your written material in English or

Spanish?

a) What is your preferred spoken language?

8. English Spanish

a)

9. Have you led a California Unemployment Insurance

or a Disability Insurance claim in the last two years?

a) If yes, list each type of claim and the most recent

date(s) of when the claim(s) was led.

9. Yes No

a) Unemployment Claim Date(s) (mm/dd/yyyy)

a) Disability Claim Date(s) (mm/dd/yyyy)

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UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

10. Do you have a Driver License issued to you by a

State/entity?

a) If yes, provide the name of the issuing State/entity

and your Driver License number.

If no, answer questions b-d:

b) Do you have an Identication Card issued to you

by a State/entity?

c) If yes, provide the name of the issuing State/entity

and your Identication Card number.

d) How do you look for work and, if you have work,

how do you get to work?

10. Yes No

a) Name of issuing State/entity:

Driver License Number:

If no, answer questions b-d:

b) Yes No

c) Name of issuing State/entity:

Identication Card Number:

d) Please Explain:

11. What is your telephone number?

a) If you are deaf, hard of hearing, or have a speech

disability and use TTY or California Relay to

communicate, check the appropriate box.

11. – –

a) TTY (Non-voice) California Relay Service

12. What is your mailing address?

(Include your city, State, and ZIP code)

12. Street: Apt.:

City:

State: ZIP Code:

13. Is your residence address the same as your mailing

address?

a) If no, enter your residence address. (Include your

city, State, ZIP code and apartment number.)

A residence address cannot be a P.O. Box. Please

provide a street address.

13. Yes No

a) Street: Apt.:

City:

State: ZIP Code:

14. If you do not live in California, what is the name of the

County in which you live?

14.

15. What race or ethnic group do you identify with? Check one of the following:

White Black not Hispanic Hispanic

Asian American Indian/Alaskan Native Chinese

Cambodian Filipino Other Pacic Islander

Guamanian Asian Indian Japanese

Korean Laotian Samoan

Vietnamese Hawaiian I choose not to answer

16. Do you have a disability? (A disability is a physical or

mental impairment that substantially limits one or more

life activities, such as caring for oneself, performing

manual tasks, walking, seeing, hearing, speaking,

breathing, learning, or working.)

16. Yes No I choose not to answer

17. What is the highest grade of school you have completed? Check only one box.

Did not complete High School High School Diploma or GED Some college or vocational school

Associate of Arts Bachelor of Arts or Science Masters or Doctorate

18. Are you a Military Veteran?

18. Yes No

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UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

19. Provide your employment and wages information for the past 18 months. If you worked for a temporary agency, a labor contractor, an

agent for actors or actresses, or an employer where wages are reported under a corporate name, your wages may have been reported

under that employer name. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer.

a) Name and mailing address of all employers you worked for in the last 18 months.

b) Period of employment (Dates Worked).

c) Total Wages earned for each employer in the last 18 months.

d) How you were paid (specify hourly, weekly, monthly, annually, commission, or at piece rate).

e) Specify if you worked full-time or part-time.

f) How many hours you worked per week.

g) Check the appropriate “Yes/No” box if the employer is (or is not) a school or educational institution or a public or nonprot employer

where you performed school-related work.

NOTE: It is important that you report the employer name(s) and mailing address(es), period(s) of employment, and wages correctly. Failure to

provide complete information will result in your benets being delayed or denied.

a) Employer Name and Mailing Address b) Dates Worked c) Total Wages d) How were you paid?

(e.g.,weekly, monthly, etc.)?

Name: From: $

Mailing Address: To:

Street:

City:

State: ZIP Code:

e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No

If yes, provide phone number: – –

a) Employer Name and Mailing Address b) Dates Worked c) Total Wages d) How were you paid?

(e.g.,weekly, monthly, etc.)?

Name: From: $

Mailing Address: To:

Street:

City:

State: ZIP Code:

e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No

If yes, provide phone number: – –

a) Employer Name and Mailing Address b) Dates Worked c) Total Wages d) How were you paid?

(e.g.,weekly, monthly, etc.)?

Name: From: $

Mailing Address: To:

Street:

City:

State: ZIP Code:

e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No

If yes, provide phone number: – –

a) Employer Name and Mailing Address b) Dates Worked c) Total Wages d) How were you paid?

(e.g.,weekly, monthly, etc.)?

Name: From: $

Mailing Address: To:

Street:

City:

State: ZIP Code:

e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No

If yes, provide phone number: – –

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UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

19. Continued

a) Employer Name and Mailing Address b) Dates Worked c) Total Wages d) How were you paid?

(e.g.,weekly, monthly, etc.)?

Name: From: $

Mailing Address: To:

Street:

City:

State: ZIP Code:

e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No

If yes, provide phone number: – –

a) Employer Name and Mailing Address b) Dates Worked c) Total Wages d) How were you paid?

(e.g.,weekly, monthly, etc.)?

Name: From: $

Mailing Address: To:

Street:

City:

State: ZIP Code:

e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No

If yes, provide phone number: – –

20. During the past 18 months did you work for any other

employers not listed in question 19?

20 Yes No

If yes, list the employer information for questions 19 a-g on a separate sheet of

paper. Attach the additional sheet of paper to this application.

21. If the EDD nds that you do not have sufcient wages

in the Standard Base Period to establish a valid claim,

do you want to attempt to establish a claim using the

Alternate Base Period?

For additional information about the Standard Base

Period and the Alternate Base Period, visit the EDD

website www.edd.ca.gov.

21 Yes No

22. During the past 18 months, which employer did you

work for the longest?

a) What type of business was operated by the

employer? (Please be specic. For example,

restaurant, dry cleaning, construction, book store.)

b) How long did you work for that employer?

c) What type of work did you do for that employer?

22. Employer name:

a) Type of business:

b) Years: Months:

c)

23. What is your usual occupation? 23.

24. Is your usual work seasonal?

If yes, answer questions a-c:

a) When does the season usually begin?

b) When does the season usually end?

c) What other work-related skills do you have?

24. Yes No

If yes, answer questions a-c:

a) (mm/dd/yyyy)

b) (mm/dd/yyyy)

c)

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UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

Please provide information about your very last employer. This is the employer you last worked for regardless of the length of

time you worked at that job, the type of work you did for that employer, or whether or not you have been paid.

If you worked for a temporary agency, a labor contractor, an agent for actors or actresses, or an employer where wages are

reported under a corporate name, your wages may have been reported under that employer name. If you worked for In-Home

Supportive Services (IHSS), the welfare recipient for whom you provided the in-home supportive service is your employer, not

the county. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer.

Reminder: To le a claim, individuals must be out of work or working less than full time. You must provide information about the

last employer you worked for as an employee. Do not include self-employment unless you have elective coverage.

25. What is the last date you actually worked for your very

last employer?

a) What are your gross wages for your last week of

work? For Unemployment Insurance purposes, a

week begins on Sunday and ends the following

Saturday.

b) What is the complete name of your very last

employer?

c) What is the mailing address of your very last

employer?

d) Is the physical address of your very last employer

the same as their mailing address? (A physical

address cannot be a P.O. Box. Please provide a

street address.)

If no, what is the physical address of your very

last employer?

e) What is the telephone number of your very last

employer at their physical address?

f) What is the name of your immediate supervisor?

g) Briey explain in your own words the reason

you are no longer working for your very last

employer, within the space provided. Please do

not include any attachments.

25. (mm/dd/yyyy)

a) $

b) Name:

c) Mailing address:

Street:

City:

State: ZIP Code:

d) Yes No

Physical address:

Street:

City:

State: ZIP Code:

e) – –

f)

g) Reason:

26. Are you (directly or indirectly) out of work with any

employer (last employer or any employer in the last

18 months) due to a trade dispute, such as a strike or

a lockout?

26. Yes No

If yes and a union was/is involved, answer

questions a-b:

If yes and a union was not/is not involved, answer questions c-e:

a) What is the name and telephone number of the

union?

Name:

Phone: – –

b) Are you going to receive strike benets?

Yes No

c) How many employees left work?

d) Was there a spokesperson for the employees? Yes No

e) If yes, what is his/her name and telephone number?

Name:

Phone: – –

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UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

27. Are you currently working for or do you expect to work

for any school or educational institution or a public or

nonprot employer performing school-related work?

If yes, answer questions a-e:

a) Provide the following information for the school or

educational institution(s) or the public or nonprot

employer(s).

b) Are you a substitute teacher for Los Angeles

Unied School District (LAUSD)?

c) Are you currently in a recess period or off track?

d) Do you have reasonable assurance to return to

work after the recess period or the off track period

with any school or educational institution?

e) What is the beginning date of your next recess or

the next off track period?

27. Yes No

If yes, answer questions a-e:

a) Name:

Mailing Address:

Street:

City:

State: ZIP Code:

Phone: – –

Name:

Mailing Address:

Street:

City:

State: ZIP Code:

Phone: – –

b) Yes No

c) Yes No

d) Yes No

If yes, when? (mm/dd/yyyy)

e) (mm/dd/yyyy)

28. Do you expect to return to work for any former

employer?

28. Yes No

29. Do you have a date to start work with any employer?

If yes, answer question a:

a) What date will you start work?

29. Yes No

If yes, answer question a:

a) (mm/dd/yyyy)

30. Are you a member of a union or non-union trade

association?

If yes, answer questions a-f:

a) What is the name of your union or non-union

organization?

b) What is your union local number?

c) What is the telephone number of your union or

non-union trade association?

d) Does your union or non-union trade association

nd work for you?

e) Does your union or non-union trade association

control your hiring?

f) Are you registered with your union or non-union

trade association as out of work?

30. Yes No

If yes, answer questions a-f:

a)

b) (Enter zero “0” for non-union trade association.)

c) – –

d) Yes No

e) Yes No

f) Yes No

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UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

31. Are you currently attending, or do you plan on

attending school or training?

If yes, answer question a-g:

a) What is the starting date of the school or training?

b) What is the ending date of the current session?

c) What is the name of the school?

d) What is the telephone number of the school?

e) What are the days and hours you are attending, or

plan to attend, school?

f) Is your school or training program authorized or

funded by one of the programs listed in section f?

NOTE: If you are in a State Approved Apprenticeship

training, you must mail your training completion

certicate with your Continued Claim Form,

DE 4581, for the week(s) of training.

g) If you had a job, or were offered a job in your

usual occupation, would the days and hours you

attend school prevent you from working full time?

31. Yes No

If yes, answer questions a-g:

a) (mm/dd/yyyy)

b) (mm/dd/yyyy)

c)

d) Phone: – –

e) Days and hours:

f) Yes No

If yes, check only one box.

Workforce Investment Act (WIA)

Employment Training Panel (ETP)

Trade Adjustment Assistance (TAA)

California Work Opportunity and Responsibility to Kids

(CalWORKS)

State Approved Apprenticeship

Union or Non-union Journey Level

None of the above

g) Yes No

32. Are you available for immediate full-time work in your

usual occupation?

a) If no, please explain why you are not available for

full-time work.

32. Yes No

a) Explanation:

33. Are you available for immediate part-time work in your

usual occupation?

a) If no, please explain why you are not available for

part-time work.

33. Yes No

a) Explanation:

34. Are you currently self-employed, or do you plan to

become self-employed? (Self-employment means

you have your own business or work as an

independent contractor.)

34. Yes No

35. Are you now, or have you been in the last 18 months

an ofcer of a corporation or union or the sole or major

stockholder of a corporation?

a) If yes, include name of organization and your title

or position.

35. Yes No

a) Name of Organization:

Title/Position:

36. Did you serve as an elected public ofcial or

Governor-exempt appointee in the last 18 months?

36. Yes No

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UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

37. Are you currently receiving a pension?

If yes, answer question a:

a) Are you currently receiving more than one pension?

If yes, proceed to question 38.

If no, answer questions b-f:

b) What is the name of the pension provider?

c) Is the pension based on another person’s work or

wages?

d) Is the pension a union pension or a pension

funded by more than one employer?

e) What is the name of the employer(s) paying into

the pension?

f) Did you work for that employer in the last

18 months?

37. Yes No

If yes, answer question a:

a) Yes No

If yes, proceed to question 38.

If no, answer questions b-f:

b)

c) Yes No

d) Yes No

e)

f) Yes No

38. Will you receive any additional pension(s) in the next

12 months?

If yes, answer questions a-b:

a) What is the name of the pension provider(s)?

b) When will you receive the pension(s)?

38. Yes No

If yes, answer questions a-b:

a)

b) (mm/dd/yyyy)

(mm/dd/yyyy)

39. Are you receiving, or do you expect to receive,

Workers’ Compensation?

If yes, answer questions a-d:

a) Who is the insurance carrier?

b) What is the insurance carrier’s telephone number?

c) What is the case number, if known?

d) What are the dates of your claim, if known?

39. Yes No

If yes, answer questions a-d:

a)

b) Phone: – –

c)

d) From: (mm/dd/yyyy)

To: (mm/dd/yyyy)

40. Have you received or do you expect to receive, any payments from your last employer, other than your Yes No

regular salary? (Example: holiday pay, vacation pay, severance pay, in-lieu-of-notice pay, etc.)

If yes, provide the information in sections A-D. If you received severance pay as a lump sum, complete sections A-C (in section C, report

the date the lump-sum payment was made).

A.

TYPE OF PAYMENT

(Example: vacation pay)

B.

AMOUNT OF PAYMENT

(Example: $600)

C.

PAID FROM

(Date: mm/dd/yyyy)

D.

PAID TO

(Date: mm/dd/yyyy)

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UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

41. Are you a U. S. Citizen or National?

If no, answer question a:

a) Are you registered with the United States

Citizenship and Immigration Services (USCIS,

formerly INS) and authorized to work in the

United States?

b) Were you legally entitled to work in the United

States for the last 19 months?

41. Yes No

If no, answer question a:

a) Yes No

b) Yes No

IMPORTANT: If you answered “yes” to question “a” above, you must select one of the USCIS documents listed in 41A through 41H

below and provide the applicable document information.

41A. Permanent Resident Card (I-551)

1) Alien Registration Number (A#)

2) Permanent Resident Card Number (CARD#)

NOTE: The CARD# is on the back of the card, next to

your photo, under the DOB and the EXP date.

3) Expiration Date (EXP)

41A. Permanent Resident Card (I-551)

1) A#

The Alien Registration Number must be 7 to 9 digits long. Enter numeric

digits only.

2)

The CARD# must be 13 characters long. Enter 3 alphabetic characters

followed by 10 numeric digits. If your current card was issued to you

before December 1997, leave this blank.

3) (mm/dd/yyyy)

41B. Employment Authorization Card (I-766)

1) Alien Registration Number (A#)

2) Expiration Date

41B. Employment Authorization Card (I-766)

1) A#

The Alien Registration Number must be 7 to 9 digits long. Enter numeric

digits only.

2) (mm/dd/yyyy)

41C. Refugee Travel Document (I-571)

1) Alien Registration Number (A#)

2) Expiration Date

41C. Refugee Travel Document (I-571)

1) A#

The Alien Registration Number must be 7 to 9 digits long. Enter numeric

digits only.

2) (mm/dd/yyyy)

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UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

41D. Arrival/Departure Record (I-94)

1) Arrival/Departure Number

2) Expiration Date

41D. Arrival/Departure Record (I-94)

1)

The Arrival/Departure Number must be 11 digits long. Enter numeric

digits only.

2) (mm/dd/yyyy)

41E. Re-entry Permit (I-327)

1) Alien Registration Number (A#)

2) Expiration Date

41E. Re-entry Permit (I-327)

1) A#

The Alien Registration Number must be 7 to 9 digits long. Enter numeric

digits only.

2) (mm/dd/yyyy)

41F. Unexpired Foreign Passport

1) Arrival/Departure Number

2) Passport Number

3) Visa Number

4) Expiration Date

41F. Unexpired Foreign Passport

1)

The Arrival/Departure Number must be 11 digits long. Enter numeric

digits only.

2)

The passport number must be 6 to 12 alphanumeric characters. It is

usually found on the top right corner of the document.

3)

The Visa Number must be 8 numeric digits.

4) (mm/dd/yyyy)

41G. Arrival/Departure Record (I94) in Unexpired

Foreign Passport

1) Arrival/Departure Number

2) Passport Number

3) Visa Number

4) Expiration Date

41G. Arrival/Departure Record (I94) in Unexpired Foreign Passport

1)

The Arrival/Departure Number must be 11 digits long. Enter numeric

digits only.

2)

The passport number must be 6 to 12 alphanumeric characters. It is

usually found on the top right corner of the document.

3)

The Visa Number must be 8 numeric digits.

4) (mm/dd/yyyy)

41H. Other Document (not listed in Section A to G)

1) Alien Registration Number (A#)

2) Arrival/Departure Number

3) Expiration Date

4) Document Description

41H. Other Document (not listed in Section A to G)

1) A#

The Alien Registration Number must be 7 to 9 digits long. Enter numeric

digits only.

2)

The Arrival/Departure Number must be 11 digits long. Enter numeric

digits only.

3) (mm/dd/yyyy)

4) Document Description:

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UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

SUPPLEMENTAL FORM FOR FEDERAL EMPLOYEES – ATTACHMENT B

Please complete the following:

1. Did you work for the Federal Emergency

Management Agency (FEMA) as a Disaster Assistance

Employee (DAE)?

1. Yes No

2. What is your state of residence? 2.

3. What is the complete name of the federal agency for

your last ofcial duty station?

a) What is the complete address of the federal

agency for your last ofcial duty station?

3. Name:

a) Address:

Street:

City:

State: ZIP Code:

4. What is your employer’s three-digit Federal

Identication Code (FIC) located on your W-2, SF 8 or

SF 50?

a) What is the federal agency name and address on

your W-2, SF 8 or SF 50?

4.

a) Name:

Address:

Street:

City:

State: ZIP Code:

5. Have you had subsequent employment since your

federal employment?

a) If yes, in what state was your subsequent

employment?

5. Yes No

a)

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UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

SUPPLEMENTAL FORM FOR DISASTER UNEMPLOYMENT ASSISTANCE (DUA) – ATTACHMENT D

Please complete the following if you are unemployed or partially unemployed due to a disaster as you may be eligible for

DUA benets:

1. Are you unemployed as a direct result of a recent

disaster in California, such as an earthquake, ood,

mudslide, wildre, etc.?

If yes:

a) Identify the type of disaster.

b) At the time of the disaster, in which county did you

reside?

c) At the time of the disaster, in which county did you

work?

d) At the time of the disaster, was your

unemployment caused by your need to travel

through a disaster area?

If yes:

Identify the disaster county or counties that

prevent travel to your job.

e) Check the following that best applies to you:

f) If you selected item e1 or e3 above, how many

hours did you work prior to the disaster?

g) If you selected e3 or e4 above briey describe

how the disaster affected your ability to continue

or begin your self-employment.

h) What is the physical address of your business?

1. Yes No

If yes, answer questions a-d:

a)

b)

c)

d) Yes No

e) 1) An employee who is unable to work as a direct result of the

disaster.

2) An individual who was scheduled to start work for an employer,

but could not because of the disaster.

3) A self-employed individual who is unable to work as a direct

result of the disaster.

4) An individual who intended to begin self-employment, but could

not because of the disaster.

5) An individual who became head of household as a result of the

disaster.

f)

g)

h) Street:

City:

State: ZIP Code:

1101I12

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UNEMPLOYMENT INSURANCE APPLICATION

Social Security number: – –

DO NOT MAIL OR FAX THIS PAGE

SUBMITTING YOUR APPLICATION

Be sure to review your application thoroughly for completeness. An incomplete application may delay or prevent the ling of your

claim, or cause benets to be denied.

Submit your completed application including any applicable attachment(s) by mail or fax:

By MAIL to the following address: EDD

P.O. Box 12906

Oakland, CA 94604-2909

NOTE: Extra postage is required.

By FAX to the following telephone number: 1-866-215-9159

Once you submit your application, allow 10 days for processing of your claim. You will receive Unemployment Insurance

(UI) claim materials by mail. If you have not received any UI claim materials after 10 days from the date you submitted your

application, call one of the following toll-free telephone numbers:

English 1-800-300-5616 Spanish 1-800-326-8937 Mandarin 1-866-303-0706

TTY (Non Voice) 1-800-815-9387 Cantonese 1-800-547-3506 Vietnamese 1-800-547-2058

Date Submitted: by Mail or Fax

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Fill Online, Printable, Fillable, Blank UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) (California) Form

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Fillable UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) (California)

Fill Online, Printable, Fillable, Blank UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) (California) Form

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