Mail Date: SSA No.: 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-Voice) 1-800-815-9387 REQUEST FOR ELIGIBILITY INFORMATION In order to be eligible for UI benefits you must attend all interviews and/or workshops the Department schedules for you to assist you in returning to work. You were scheduled for a mandatory Reemployment Eligibility and Assessment (REA) appointment on . You did not attend your scheduled REA appointment. The reason you did not attend may affect your eligibility for benefits. Please provide answers to the appropriate questions below and mail with the enclosed Reemployment and Eligibility Assessment Questionnaire to the EDD office address listed above. Failure to complete and return both forms within 10 days of the mailing date listed above will be cause for denial of benefits. Indicate why you did not attend the REA appointment by marking the box that pertains to the reason(s) you did not attend. If the reason you did not attend is not shown, please check the "Other" box and write a complete explanation on the reverse of the form. The information you supply will be used to determine whether you are eligible for benefits. We will not contact you for more information before issuing a decision; therefore, it is important to fully explain why you did not attend. Attach additional sheets if necessary. Always include your Social Security Number on any additional documents. 1. Worked on the day of the REA appointment or attended a job interview on the day of the REA appointment. The Department may contact the employer to verify the information provided. Be sure to provide the correct information requested below. If we are unable to verify the information, benefits will be denied. Provide the following information: · Employer Name: _________________________________________________________________ · · · · 2. Address: _______________________________________________________________________ Telephone Number: ______________________________________________________________________________ Position interviewed for: ___________________________________________________________ If you attended a job interview, also provide the following information: Name of person who interviewed you: ________________________________________________ Other: In order to be eligible for UI benefits, you must be able and available for work and actively seeking work each week you claim benefits. The reason you did not attend may be cause for denial of benefits. Please answer the questions on the reverse. Use the reverse side of this form to provide your statement. DE 4365REA Rev. 1 (4-06) (INTERNET) Page 1 of 4 CU American LegalNet, Inc. www.USCourtForms.com Explain below why you did not attend the REA appointment by answering the following questions. 1. Explain in detail the situation that prevented you from attending the REA appointment. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 2. What date and time did the situation begin that caused you to miss the REA appointment? ______________________________________________________________________________________ What date and time did the situation end, or what date and time do you expect the situation to end? ______________________________________________________________________________________ 3. Did you try to resolve this situation in order to attend the REA appointment? Yes No If yes, what steps did you take? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 4. Could you have gone to work on the day of the REA appointment if work was available? No Yes I understand the law provides penalties if I make false statements or withhold facts to obtain benefits. I declare under penalty of perjury that the information I am providing is true and correct. PRINT YOUR NAME SIGNATURE DATE DE 4365REA Rev. 1 (4-06) (INTERNET) Page 2 of 4 CU American LegalNet, Inc. www.USCourtForms.com REEMPLOYMENT AND ELIGIBILITY ASSESSMENT QUESTIONNAIRE Name: _____________________________ 1. List your usual occupation(s) __________________________________ __________________________________ Social Security Number: ____________________ Length of experience _________________ _________________ Last rate of pay _____________ _____________ 2. Date you were last employed: ____________________ 3. What type of work are you seeking? ______________________________________________________________ 4. Lowest Wage you will accept to start work: _________ Hourly: _______ Week:ly: _______ Monthly: ________ 5. What work shift(s) are you willing to accept? ________________________________________________________ 6. What transportation will you use to and from work? ___________________________