Sweetestlilfreak

Sweetestlilfreak

For Department Use Only Date Received: Date Postmarked/Faxed: Effective Date:

UNEMPLOYMENT INSURANCE APPLICATION
(Ex-Servicemember)
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 filing of your claim, or cause benefits to be denied. If the Department needs to verify any of the information you provide while filing 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. What is your Social Security Number as given to you by the Social Security Administration? a) If EDD assigned you an EDD Client Number (ECN), please provide the ECN here. (An ECN is a 9-digit number beginning with 999.) 2. List any other Social Security Numbers you have used. 3. What is your full name? 2. 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 1. a)

a) Last ___________________________________________ First ___________________________________________ Middle Initial ____ 5. __________________________________________________ __________________________________________________ 6. 7. 8. Male English Female Spanish (mm/dd/yyyy)

5. List any other names you have used. 6. What is your birth date? 7. What is your gender? 8. Would you prefer your written material in English or Spanish? a) What is your preferred spoken language? 9. Have you filed a California Unemployment...