PRIOR WAGES NOTICE CORRECTION/UPDATE REQUEST 1. California Employer Account Number: 2. Business Name: 3. Other Business Names: 4. Mailing Address: (City) (Address) (State) (Zip Code) (8 Digit Code) 5. Phone Number: ( (Area Code) ) (Phone Number) 6. Prior Wages Notice Number : 7. Date of Prior Wages Notice: Complete Section A if you are reporting a correction required on a current Wages Notice. Complete Section B if you need to update a prior Wages Notice to reflect a more recent layoff. Section A: Wages Notice Correction 8. Please explain what corrections are necessary to the Wages Notice. Section B: Wages Notice Update 9. Please provide the following information regarding the current layoff: Date(s) of Layoff (MM/DD/YY­MM/DD/YY) Number of California Employees Laid Off Location(s) of Affected Job Sites in California (City) DE 4809 Rev. 5 (11-15) (INTERNET) Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CU 10. Will employees affected by the current layoff receive the same payments under the same company policy described in the prior Wages Notice? Yes No If no, please explain the policy and/or payments. 11. Please provide the following information regarding payments which will be paid to employees affected by the current layoff: Type of Payment Period Covered by Payment (if applicable) (MM/DD/YY­MM/DD/YY) Work Group Eligible to Receive Payment 12. Comments: Employer Representative/Agent: Name: Title: Phone Number: ( (Area Code) ) (Phone Number) Mailing Address (if different than the business address): DE 4809 Rev. 5 (11-15) (INTERNET) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CU INSTRUCTIONS FOR PRIOR WAGES NOTICE UPDATE/CORRECTION REQUEST The Employment Development Department will prepare a Wages Notice based on the information you provide. The Department issues a Wages Notice to reduce the number of calls to employers and to promote consistent decisions from Department staff regarding payments received by unemployment insurance (UI) claimants. The Wages Notice will provide Department staff with general information regarding the post-employment payments and a determination of whether the payments will affect the claimants' eligibility for UI benefits. The Department will also mail you a copy of the Wages Notice for your records. Please follow the instructions carefully: 1. CALIFORNIA EMPLOYER ACCOUNT NUMBER ­ Enter your California state employer account number. 2. BUSINESS NAME ­ Enter the name by which your business is known. 3. OTHER BUSINESS NAMES ­ Enter other names by which your business is known and which your employees may report as their employer. 4. MAILING ADDRESS ­ Provide business mailing address. 5. PHONE NUMBER ­ Enter business phone number including area code. 6. Enter the number of the Wages Notice that you would like us to correct or update. 7. Enter the issue date of the Wages Notice that you would like us to correct or update. Section A: Wages Notice Correction Complete this section if you would like to report information you feel needs to be added or corrected on a current Wages Notice. 8. Provide specific information regarding the required changes. If appropriate, be sure to include any pertinent dates, eligibility requirements, payment type, amounts, etc. Section B: Wages Notice Update Complete this section if you are providing information on a more recent layoff and would like us to update a prior Wages Notice. 9. If you have different layoff periods list them separately. DATE(S) OF LAYOFF ­ Enter the date(s) you laid off or plan to lay off the employees. If layoffs will occur over a period of time and you do not have specific dates, you may indicate anticipated beginning and ending dates. Example: 02/05/14 ­ 06/30/14 NUMBER OF CALIFORNIA EMPLOYEES LAID OFF ­ Enter the total number of employees who work in California and who will be laid off during the period indicated. LOCATION(S) OF AFFECTED JOB SITES IN CALIFORNIA ­ Enter the name(s) of the California city/cities where the job site(s) affected by the layoff is (are) located. If several job sites throughout California are affected you may indicate "statewide" rather then listing the individual job sites. DE 4809 Rev. 5 (11-15) (INTERNET) Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CU 10. If there are any additional payments not addressed in the prior Wages Notice, describe the different payments, basis for payments, eligibility requirements, etc. 11. List the payments, other than wages through the last day worked and accrued vacation, that employees affected by the current layoff will receive. TYPE OF PAYMENT ­ Enter what the company calls the payment. PERIOD COVERED BY PAYMENT ­ If the payment covers a specific period of time, enter the dates. For example, if you are reporting in-lieu-of-notice pay you would enter the date through which employees are in receipt of in-lieu-of notice pay. WORK GROUP ELIGIBLE TO RECEIVE PAYMENT ­ Enter the work group that will receive the payment if it is only a specific group of employees, e.g., assembly line workers, hourly employees, represented employees, etc. If the layoff involves several sites and only employees at some sites will receive the pay, you may enter site location under Work Group. If all employees affected by the layoff will receive the payment, no entry is required. 12. COMMENTS ­ Provide any additional information regarding the payments that you feel is important and can assist the Department in determining if the payments will affect the employees' eligibility for UI benefits. For more information about completing this form, please call (916) 403-6358 and ask to speak to a representative in the Wages Notice Group. You may FAX the completed form to (916) 449-2192, or mail to Employment Development Department, UI Integrity and Accounting Division, MIC 16A, Wages Notice Group, P.O. Box 2228, Rancho Cordova, CA 95741-2228. DE 4809 Rev. 5 (11-15) (INTERNET) Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CU