WAGES NOTICE REQUEST SEPARATION PAY/OR IN-LIEU-OF-NOTICE PAY INFORMATION 1. California Employer Account Number: __________________________________________________ 2. Business Name: ___________________________________________________________________ 3. Other Business Names:______________________________________________________________ 4. Mailing Address: ___________________________________________________________________ _________________________________________________________________________________ (City) (State) (Zip Code) (Address) (8 Digit Code) 5. Phone Number: (_____) _____________________________________________________________ (Area Code) (Phone Number) 6. Please provide the following information (if you have different layoff periods list them separately): Date(s) of Layoff (MM/DD/YY­MM/DD/YY) Number of California Employees Laid Off Location(s) of Affected Job Sites in California (City) 7. Union Name, Local, and Phone Number (if applicable): _____________________________________ 8. Prior Wages Notice Number (if applicable): ______________________________________________ 9. Will the terminated employees receive any payments other than their regular wages through their last day worked and accrued vacation? ____ Yes ____ No If no, it is not necessary to complete this form. Issuance of a Wages Notice is only necessary if your company will pay post-employment payments to the terminated employees. SEPARATION PAY INFORMATION: 10. Does the company have a plan or policy that provides for separation payments when there is a reduction in force or closure? ____Yes ____No 11. What is the basis for the payments (i.e., written policy, general practice, new policy for this reduction in force, collective bargaining agreement, etc.)? 12. What does the company call these payments? 13. What is the purpose of the payments? 14. Who is eligible to receive the payments? 15. Do the employees continue to accrue all service credits, such as seniority, vacation time, etc., during the period covered by the payment(s)? ____Yes ____No 16. Will the company make the payments in a ____ lump sum and/or ____ periodic payments? (check accordingly) DE 4808 Rev. 5 (11-15) (INTERNET) Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com CU IN-LIEU-OF-NOTICE PAY INFORMATION: 17. Does company policy provide that advance notice be given in the event of a layoff or that payment be made in lieu of such notice? ____Yes ____No If yes, please explain company policy. If no, please explain the reason for the payments. 18. Do the employees continue to accrue all service credits, such as seniority, vacation time, etc., during the period covered by the payment(s)? ____Yes ____No 19. Does the company retain the right to call on the employees' services, if needed, during the period covered by the payments? ____Yes ____No 20. Will the company make the payments in a ____ lump sum and/or ____ periodic payments? (check accordingly) 21. Please provide the following (if you issued layoff notices on different dates, please list each issuance separately): Affected Work Group Date Employees Notified (MM/DD/YY) Termination Effective Date (MM/DD/YY) Employees' Last Work Day (MM/DD/YY) Employees Paid Notice Pay Through (MM/DD/YY) GENERAL INFORMATION: 22. Are the terminated employees covered by a pension plan? ____Yes ____No If yes, did the terminated employees at any time contribute to the pension fund and are those contributions still part of the pension fund? ____Yes ____No If no, is the pension based solely on employer contributions? ____Yes ____No DE 4808 Rev. 5 (11-15) (INTERNET) Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com CU 23. Does the company have any other plans set up for retirement purposes? ____Yes ____No If yes, please provide: Type of plan: Who can participate in the plan? Who contributes to the plan? ____ Employee ____ Company ____Both employee and company What are the terminated employees' options with respect to the contributions in the plan? 24. Did any of the terminated employees elect voluntary layoff/retirement or refuse a transfer within the company in lieu of lay off? ____Yes ____No If yes, please explain. 25. Did any of the terminated employees elect to be laid off in place of less senior employees? ____Yes ____No If yes, are those employees covered by a collective bargaining agreement that provides for substitutionary layoff? ____Yes ____No 26. If the layoff was due to a merger, acquisition, etc., did any of the affected employees refuse an offer of work from the new company? ____Yes ____No ____Not applicable If yes, please provide: Name of the new company: Contact person: 27. Comments: Phone number: ( (Area Code) ) (Phone Number) Employer Representative/Agent: Name: Title: Phone Number: ( (Area Code) ) (Phone Number) Mailing Address (if different than the business address): _______________________________________ ______________________________________ ______________________________________ DE 4808 Rev. 5 (11-15) (INTERNET) Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com CU INSTRUCTIONS FOR WAGES NOTICE REQUEST SEPARATION PAY/OR IN-LIEU-OF-NOTICE PAY INFORMATION 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 received by terminated employees 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. 2. 3. 4. 5. 6. CALIFORNIA EMPLOYER ACCOUNT NUMBER - Enter your California state employer account number. BUSINESS NAME ­ Enter the name by which your business is known. OTHER BUSINESS NAMES ­ Enter other names by which your business is known and which your employees may report as their employer. MAILING ADDRESS ­ Provide business mailing address. PHONE NUMBER ­ Enter business phone number including area code. 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 anticipa