Fillable Printable Continued Claim Form (De 4581Cto)
Fillable Printable Continued Claim Form (De 4581Cto)
Continued Claim Form (De 4581Cto)
SAMPLE
ALLOW 10 DAYS FOR DELIVERY OF CHECK.
DETACH THIS STUB FOR YOUR RECORD
CONTINUED
CLAIM
IST WEEK
2ND WEEK
Begins
Ends
Begins
Ends
ANSWER ALL QUEST I O N S. SEE SECTIO N A. ON BACK FOR EXAMPLES
OF HOW TO COMPLETE YOUR ANSWERS . Each question is explained
in your booklet, A Guide to Benefits and Employment Services.
COMPLETE AND MAI L THIS FORM ON
YES
NO
YES
NO
1. Were you too sick or injured to work?
>
If yes, enter the number of days (1 through 7) you were unable to work.
>
(I - 7)
(I - 7)
2. Was there any reason (other than sickness or injury) that you could not have
accepted full-time work each workday? >
3. Did you look for work? >
<
IF MARKED 'X', YOU MUST COMPLETE SEC. B., WORK-SEARCH RECORD, ON REVERSE.
4. Did you refuse any work?
>
5. Did you begin attending any kind of school or training? >
6. Did you work or earn any money, WHETHER YOU WERE PAID OR NOT?
>
(If yes, you MUST COMPLETE items a. and b. below.)
$
a. Enter earnings before deducti ons here.
$
b. Report employment or 'source' of earnings inf orm ation bel ow:
7. If you want federal income tax withheld for the week(s) shown above,
mark this block.
>
8. If you had a change of mailing address or phone number,
mark this block and complete Sec. D on reverse.
>
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 an d co rr ec t. I dec lar e un der pen alt y of per jury tha t I am a U.S . ci t izen or
national; or an alien in satisfactory immigration status and permitted to work by
USCIS. I signed this form after the late st date fo r w hic h I am clai m ing ben efi ts .
X
(your signature is required)
DE 4581CTO Rev. 6 (5-04) (INTERNET) Page 1 of 2 CU-PA866
DETACH AND DISCARD
DATE
LAST WORKED
TOTAL
HOURS WORKED
EMPLOYER NAME AND MAILING ADDRESS - INCLUDE ZIP CODE
REASON NO LONGER WORKING
(OR WRITE "STILL WORKING")
1ST WEEK
2ND WEEK
>
SAMPLE
Section A / Sección A The following are examples of how to complete your answers to the questions on the front of this form.
Los siguientes son e jemplos en como completar sus respuestas a las pregunt as en el frente de este formulario.
Write numbers like this:
EXAMPLE: Report earnings of: (a) $76.10 (b) $342.58 (c) $1050.55, like this:
EJEMPLO: Reporte ingresos de: (a) $76.10 (b) $342.58 (c) $1050.55 asi:
(a) $ 7 6 1 0
Section B / Sección B If the box under Question 3 on the reverse is marked "X", you must complete the table below to show your
work searc
h for the weeks being claimed. / Si el cuadrado en la pregunta #3 en el reverso está marcado con una "X", usted debe de
completar la tabla a continuación para indic ar su búsqueda de
traba jo durante la(s) semana(s) que solicita beneficios.
Section C / Sección C Notice to Educational Institution (FOR EMPLOYMENT DEVELOPMENT DEPARTMENT APPROVED TRAINING ONLY)
Aviso para La Institución Educaci onal
(PARA CURSOS DE ENTRENAMIENTO APROBADO POR EL DEPARTAMENTO DEL DESARROLLO DEL EMPLEO (EDD))
If you are on a semester/holiday recess, enter the date you are scheduled to return to school.
Si Ud. está en vacaciones/dias feriados del semestre esc ol ar; escri ba la fecha en que regresará a la escuela:
Section D / Sección D New Mailing Address / Nueva Dirección de Correo
DE 4581CTO Rev. 4 (5-04) State of California / Employment Development Department (INTERNET) Page 2 of 2
CU-PB318
MIC 62
Complete below and mark Question 8 block on front / Complete abajo y marque la pregunta 8 en el frente.
New phone - include area code / Nuevo número
de teléfono
- incluyendo área telefónica
( )
Zip Code: / Zona Postal:
I certify that this individual was enrolled in and
satisf act orily pursui ng the ret rai ning course of
Signature/Title Date
instruction approved by the Employment
Development Department during the
week(s) Name of Training Instit ution
shown on the front of this form
WORK-SEARCH RECORD / RÉCORD DE LOS LUGARES DO NDE HA BUS CADO T RABAJ O
Date Applied
/Fecha en que
Solicit ó Empleo
Company Name /
Nombre de la
Compañía
Company Address /
Direcci ón de la
Compañía
Person Contacted /
Persona con quien
se Comunicó
Type of Work Applied
For / Cl ase de Traba jo
que Solicit ó
Results: Please explai n /
Resultado: Por favor
Explique
Escriba números como estos:
0 1 2 3 4 5 6 7 8 9
MARK THE CORRECT ANSWE R
EXAMPLE: IF THE ANSWER IS "YES":
MARQUE LA RESP UES T A CORRECTA
EJEMPLO: SI LA RESPUESTA ES "SÍ": Sí
SI LA RESPUESTA ES "NO": Sí
IF THE ANSWER IS "NO " :
Yes No
Yes No
No
No
(c)
$ 9 9 9 9 9
(b)
$ 3 4 2 5 8
