AUTHORIZATION FOR RELEASE OF UNEMPLOYMENT INSURANCE RECORDS FOR RETIRED ANNUITANT To: Employment Development Department Orange County Primary Call Center P.O. Box 5007 Buena Park, CA 90622 , authorize the Employment Development PRINT YOUR NAME I, Fold Here Department (EDD) to release my Unemployment Insurance (UI) information for purposes related to Government Code section 21224 [Retired Annuitant (RA) return to work prohibition for a CalPERS employer if UI benefits collected within the last 12 months] to: TO: NAME AND TITLE STATE AGENCY MAILING ADDRESS CITY, STATE, AND ZIP CODE Appointing entity must include a stamped self-addressed return envelope with each request. Fold Here Date: MONTH/DAY/YEAR Signature: RETIRED ANNUITANT SIGNATURE Social Security Number: Date of Appointment: Failure to sign this consent does not preclude the appointing entity authority from obtaining this information from the EDD after you are hired, pursuant to California Unemployment Insurance Code section 322. RA Declined to Sign Consent Authorization TO BE COMPLETED BY EDD APPOINTING AGENCY REPRESENTATIVE SIGNATURE PRINT NAME (This Authorization shall remain in effect for 12 months from the date signed.) Were UI benefits paid to the above individual in the last 12 months? YES NO If yes, date last paid: For week ending: If yes, base period employer names: S T A M P DATE RECEIVED BY EDD CONFIDENTIALITY NOTICE: This notice is for the sole use of the intended recipients. It contains confidential or sensitive information. Under Penal Code 502 and Civil Code 1798.53, any unauthorized review, use, disclosure, or distribution of the content of this document is prohibited and subject to criminal penalties/fines. If you are not the intended recipient, please contact the EDD. DE 1181 Rev. 2 (11-08) (INTERNET) Page 1 of 1 CU American LegalNet, Inc. www.FormsWorkflow.com