Login

Fillable Printable Notice Of Unemployment Insurance Claim Filed (De 1101Cz)

Fillable Printable Notice Of Unemployment Insurance Claim Filed (De 1101Cz)

Notice Of Unemployment Insurance Claim Filed (De 1101Cz)

Notice Of Unemployment Insurance Claim Filed (De 1101Cz)

NOTICEOFUNEMPLOYMENTINSURANCECLAIMFILED
MailDate:
NewClaim:
AdditionalClaim:
Failure to respondwithin10calendardaysmay
resultinanincreasedemploymenttax rateand
employerpenalties.
Youreceivedthisnoticebecausetheclaimantshownbelowfiled a claimforunemploymentinsurancebenefitsand
listedyouashis/hermostrecentemployer.Theclaimantprovidedthefollowinginformation:
Claimant’s Name:Social SecurityNumber:
EffectiveDateofClaim:LastDateWorked:
ReasonforSeparation:
REPORTINGFACTS
Thelaw requiresyoutosubmitanyfactsinyourpossessionwhichmay affect a claimant'seligibilityforbenefits.Thesefacts
willbeusedindeterminingtheclaimant'seligibilityforbenefits. Provide informationtotheEmploymentDevelopment
Department(EDD)ifthisclaimant:
Voluntarilyquit,wasdischarged, orfired.
Isworking, whetherfull-timeorpart-time.
Performed servicesas a sportsorathleticparticipant.
Isa schoolemployeeandhas a contractfororreasonable
assuranceofreturningtoworkfollowing a recess.
Leftworkbecauseof a strikeortradedispute.
Hasrefusedemployment.
IsnotlegallyentitledtoworkintheU.S.
Isnotabletowork,availableforwork,orseekingwork.
Is receivinga pension.
TIMELIMITSFOR REPLYING
SubmitfactsinwritingtotheEDDintheenvelopeprovidedwithin10calendardaysfrom theabovemaildatetobe
consideredtimely. If yourmailingislate, explainyourreasonfordelayasthetimelimitmaybeextendedonlyforgood
cause. Ifyourespondtimely, you willbeissued a writtennoticeoftheEDD'sdeterminationconcerningtheclaimant's
eligibilitywhichwillprovideyouwithappealrights.Inaddition, iffactsare submittedregardinga quit ordischarge, youwill
beissueda rulingastowhetheryour reserveaccountwillbesubjecttochargesifyouare a tax-ratedemployer. Ifyou
responduntimely,theEDDwillstillconsiderthefactsprovidedbyyou.However,you maynotbeissueda writtennoticeof
theEDD's determination,includingappealrights, unlesstheEDDdeterminesthatyouhadgoodcauseforthedelay. Ifyou
acquirefactsthatcouldnothavereasonably beenknownwithinthis10-dayresponseperiod,providethesefactstothe
EDDwithin10calendardaysofacquiringthem.
ELIGIBILITYDET
ERMINATIONINTERVIEW
Itmay benecessarytocontactyoubyphoneorletterforadditionaleligibilityinformation. Ifnoresponseisreceived, the
EDDisrequiredtomakeaneligibilitydeterminationbasedonavailableinformation.
EMPLOYER REQUIREMENTSAND POTENTIAL PENALTIES
TheCaliforniaUnemploymentInsuranceCode (CUIC) providespenaltiesforemployerswho:
Willfullymakefalsestatementsorrepresentations, orwillfullyfailtoreporta material factinconnectionwitha separation
issueor a writtenstatementconcerningreasonableassuranceof a claimant'sreemployment(CUIC Section1142).
Willfully makea falsestatementorknowingly failtodisclose a materialfacttoobtain, increase,reduce, ordefeatany
paymentofbenefits(CUIC Section2101).
Failtorespondtimelyoradequately torequestsoftheDepartmentforinformationandareatfaultforcausing
overpaymentofbenefits(CUICSection803(d),821(c), and1026.1).
Formoreinformationonfraudandpenalties, visitwww.edd.ca.govandselecttheFraudandPenaltieslink.
DE1101CZ Rev. 8 (10-17)(INTERNET)1 of 2 CU
ACTIONREQUIRED
1.
Gatherthenecessaryfacts forthisclaim.
2.
Completethereversesideofthisform.
3.
Mailthisresponsewithin10calendardaysofthe
abovemaildatetotheaddressshownabove.
Employment Development Department
PO Box 989059
West Sacramento, CA 95798-9059
Name
Address
City , StateZIP
SAMPLE
Checkthisboxifyouareanagentor third partyadministratorandnolongerrepresentthisemployer.CompletetheEmployer
andContactInformation sectionbelowandreturn thisform totheEDD.
Reporting Facts:
Claimant'sSocialSecurityNumber (fromyour payrollrecords):
-
-
Claimant's JobTitle:RateofPay $:per:
LastDatePhysicallyWorked:LengthofEmployment:
DateofSeparation (ifdifferentfrom lastdatephysically worked):
Nameofimmediatesupervisor:
Reason for Separation(Checkonlyone):
VoluntaryQuit
Misconduct/Fired
LaidOff/LackofWork*
TradeDispute
Whodidtheclaimantnotifyofthequit?/Whoterminatedtheclaimant?
Person'sJobTitle:
*Do notsubmitthis formtothe EDDiftheclaimantwaslaid off dueto lackofworkandnoothereligibilityissuesexist.
Providea briefexplanationofthefinalincidentthatresultedintheclaimant'sseparation:
Compensation:
Checkthisboxifyoupaidorwillpayanycompensation, aside from regularsalary, coveringanytimeonoraftertheeffective
dateofthisclaim. Donotcheckthisboxif theclaimanthasbeenseparatedfrom youremployforanindefiniteperiodandhas
or willreceiveonlyvacationpay.
Ifyoucheckedthebox, please providethe followinginformation:
Amount$:Type ofPayment: forperiodfrom through
Employerand Contact Information:
Employer Name:
Employer PayrollTaxAccountNumber:
By signingbelow,I certifythat I amanauthorizedrepresentativeandtheinformationprovidedinresponsetothisnoticeis
true andcorrect. I understandthatanyfalsestatement,falserepresentation,orfailuretoreport a materialfactmay resultin
employerpenaltiesandcharges.
Print Name: Phone
No:
-
-Ext.:
Signature: Title:Date:
DE1101CZ Rev. 8 (10-17)(INTERNET)2 of 2
Didyouknow?Youcanelectronicallyreceiveandrespondtofuturerequestsfor separationinformationbyusingtheState
Information Data ExchangeSystem(SIDES). To getstarted, visitthe SIDES webpageat
www.edd.ca.gov/SIDES
.
SAMPLE
Login to HandyPDF
Tips: Editig or filling the file you need via PC is much more easier!
By logging in, you indicate that you have read and agree our Terms and Privacy Policy.