Fillable Printable Request For Eligibility Information Non-Attendance At Mandatory Additional Service (De 4365Res)

Request For Eligibility Information Non-Attendance At Mandatory Additional Service (De 4365Res)

REQUEST FOR ELIGIBILITY INFORMATION

NON-ATTENDANCE AT MANDATORY ADDITIONAL SERVICE

In order to be eligible for Unemployment Insurance benefits, you must attend all interviews and/or

appointments the Employment Development Department schedules for you to assist you in returning to work.

You did not attend the mandatory additional reemployment service on which you agreed to attend when

you signed the reemployment plan. The reason you did not attend may affect your eligibility for benefits.

Indicate why you did not attend the scheduled additional service by marking the box that pertains to the

reason(s) you did not attend on the back of this form. If you were working or had a job interview on the day of

the additional service or have a future date to return to work, provide all the requested information for question

#1 on the back of the form. If you were not working or attending a job interview, answer question #2 and

provide a complete explanation of the reason you did not attend the additional service appointment. Attach

additional pages, if necessary, to provide a full explanation and always include your Social Security number on

each additional page. We will not contact you for more information before issuing a decision; therefore, it is

important to fully explain why you did not attend. The information you provide will be used to determine

whether you can be paid UI benefits.

PLEASE ANSWER THE APPROPRIATE QUESTIONS ON THE BACK OF THE FORM THAT APPLY TO

YOU AND MAIL IT TO THE ADDRESS LISTED ABOVE WITHIN 10 CALENDAR DAYS OF THE MAIL

DATE OF THIS NOTICE. FAILURE TO COMPLETE AND RETURN THIS ENTIRE FORM WITHIN 10

CALENDAR DAYS MAY RESULT IN THE DENIAL OF BENEFITS FOR THE WEEK OF THE MI SSED

APPOINTMENT.

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Mail Date:

SSN:

EDD TELEPHONE NUMBERS:

ENGLISH 1-800-300-5616

SPANISH 1-800-326-8937

CANTONESE 1-800-547-3506

MANDARIN 1-866-303-0706

VIETNAMESE 1-800-547-2058

TTY (non-v oice) 1-800-815-9387

1. Did you work on the day of the additional service or attend a job interview on the day of the

additional service? Yes

If yes, answer the questions under A or B. Be sure to provide the correct information requested below.

The Department may contact the employer to verify the information provided. If we are unable to verify

the information, benefits will be denied.

A. Provide the following information:

• Employer Name and telephone number:

• Address:

B. If you attended a job interview, also provide the following information:

• Position interviewed for:

• Name of person who interviewed you:

C. If you have a definite date to return to work in the future, provide the date you will begin work

and the following information:

• Employer Name and telephone number:

• Address:

2. If you did not work or have a job interview on the day of the additional service, then explain

why you did not attend the additional service by answering the following questions.

A. Explain in detail the situation that prevented you from attending the additional reemployment service.

B. What date and time did the situation begin that caused you to miss the reemployment service?

What date and time did the situation end, or what date and time do you expect the situation to end?

C. Did you try to resolve this situation in order to attend the reemployment service? Yes No

If yes, what steps did you take?

D. Could you have gone to work on the day of the Reemployment service if work was available to you or

you had been offered work on that day? Yes

I understand the law pr ovides penalties if I make false st atements or withhold facts to obtain benefits. I declare under

penalty of perjury that the information I am pr oviding is true and correct.

PRINT YOUR NAME SIGNATURE DATE

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