1)PleaseselecttheboxofthetypeofWorkSharingplanyouwouldliketofile:Note:Torenewaplananewapplicationmustbereceivednolaterthan10daysaftertheexpirationdateofthepriorplan.Ifrenewing,howmanyadditionalWorkSharingCertifications,DE4581WSdoyouneed?2)EmployerInformationName/DBA: BusinessType: EmployerAccountNumber:2262263)EmployerContactInformationPrimaryContact AlternateContact Name: Name: Address: Address: Phone: Phone: 4) Yes NoWilltheWorkSharingoccurinadifferentlocationthantheaddressprovidedabove?Ifyes,pleaseprovidethealternatecontactandlocationinformationbelow:Name(ifdifferent): Name(ifdifferent): PhoneNumber: PhoneNumber: Address: Address: 5) Yes NoIsyourbusiness/organizationapublicentity?Pleasechecktheappropriateboxbelow.6) Yes NoYourparticipationintheWorkSharingprogramisstrictlyconfidential.OccasionallytheEmploymentDevelopmentDepartment(EDD)receivesrequestsforthenamesofcompaniesthatwouldbewillingtosharetheirexperienceswiththisprogram.Areyouwillingtohaveyournameandcontactinformationreleasedforthispurpose?7)Fillinthetableforthefull-timeandpart-timeworkforcewhowillbecoveredbytheWorkSharingplan. DE8686Rev.(-17 Page1of5CU WorkSharing(WS)UnemploymentInsurancePlanApplicationMail:EmploymentDevelopmentDepartmentQuestions?916-464-3343 New Renewal ExpandedCoverageRequestedplanstartdate(mustbeaSunday): City County State Federal SchoolDistrict Other(Specify) a)Department/UnitName b)NumberofemployeesinDept/Unit c)NumberofemployeesinDept/UnitwhowillparticipateinWS d)UsualweeklyhoursofemployeesinaffectedDept/Unit e)Estimated%ofweeklyhoursreduced 1. 2. 3. Total:Total:Total:Total: EDDUSEONLYFirstContactDate: EffectiveDate: WSEE: %: SIC: Union(Y/N) Layoff(Y/N) American LegalNet, Inc. www.FormsWorkFlow.com 8)Checktheboxbelowwiththeappropriatepayperiodcycle:Ifyourpayperiodisweeklyorbi-weekly,selectthepayrollendingdaybelow:9) Yes NoIfyouwerenotapprovedtoparticipateintheWorkSharingprogram,wouldyourbusinesslayoffworkers?10)EstimatethenumberofemployeeswhowouldneedtobelaidoffifyouwerenotparticipatingintheWorkSharingprogram:11)DescribethecircumstancesrequiringyouruseoftheWorkSharingprogram: 12)HowdoyouplantonotifyyouremployeesoftheWorkSharingprogram?13) Yes NoWilladvancenoticebegiventotheaffectedemployees?Ifnot,pleaseexplainwhyadvancenoticeisnotfeasible: 14) Yes NoAreanyparticipatingemployeescoveredbyaunion/collectivebargainingagreement?Ifyes,thebelowsection(s)mustbecompleted:15)DoesyourWorkSharingplaninvolve:a. Yes NoAtleasttwoemployees?b. Yes NoAtleast10percentofyourworkforceorworkunit(s)?c. Yes NoAtleasta10percentreductionandnomorethan60percentinBOTHhoursworkedandwageseachweek?16) Yes NoWillareductioninhealthbenefitsbescheduledtooccurduringthedurationoftheWSplan?Ifyes,answerthefollowingquestion.a. Yes NoIfso,willthosereductionsbeappliedequallytoallemployees(includingthosewhoarenotparticipatingintheWSplan)?17) Yes NoWillareductioninretirementbenefitsbescheduledtooccurduringthedurationoftheWSplan?Ifyes,answerthefollowingquestion.a. Yes NoIfso,willthosereductionsbeappliedequallytoallemployees(includingthosewhoarenotparticipatingintheWSplan)? DE8686Rev.(-17 Page2of5 WorkSharing(WS)UnemploymentInsurancePlanApplicationMail:EmploymentDevelopmentDepartmentQuestions?916-464-3343 Memo/Letter Email StaffMeeting Other(Specify) UnionName: UnionLocalNumber: PhoneNumber: NameofAuthorizedUnionRepresentative: PositionTitle: AuthorizedUnionRepresentativeSignature: Date: Mon Tues Wed Thur Fri Sat Sun Weekly Bi-weekly Monthly Other(Specify) UnionName: UnionLocalNumber: PhoneNumber: NameofAuthorizedUnionRepresentative: PositionTitle: AuthorizedUnionRepresentativeSignature: Date: American LegalNet, Inc. www.FormsWorkFlow.com Bysigningthisapplication,weunderstandandcertifythefollowingistrueandcorrect:1.WeunderstandthatbyparticipatingintheWSprogramourreserveaccountwillbechargedintheusualmannerormayhaveanadverseeffectonourtaxrate.2.Weunderstandthatifweareaparticipatingreimbursableemployer,wewillbebilledquarterlyforthecostofbenefitspaid.3.WeunderstandthatwearenottoutilizetheWSprogramfortotallayoffsduringtheholidayweeks.4.WeunderstandthataholidaycannotbeusedasaWSdayunlesstheemployee(s)inthesamepositionperformedservices(andwaspaidforthoseservices)asapartofaregularworkweek,duringthe12monthspriortotheemployer222sparticipationintheWSprogram.5.WeunderstandthatanyemployeeontheWSprogrammusthaveworkedatleastonenormalworkweekwithnoreductionspriortotheissuanceofcertificationformsforbenefitpayments.6.Weunderstandthatifemployeesareattachedtoaschooldistrictand/ornon-profitentitythatwewillprovidedatestheemployee(s)arebetweensuccessiveacademicterms/recessperiods.7.WeunderstandthattheplanapprovedbytheEDDshallexpire12monthsafteritseffectivedate.8.Weunderstandthatwemustcontinuetoprovidehealthandretirementbenefitsunderthesametermsandconditionsaswhentheaffectedemployeesworkedhis/herusualweeklyhours,unlesshealth/retirementbenefitschangeforallemployees(includingemployeesnotparticipatingintheWSplan).9.Weunderstandthatwemustprovidetheweeklypercentageofreductionsinhoursandwagesforeachparticipatingemployee,andwemustfurnishallreportsandinformationasrequestedbytheEDDtomonitorandreviewourWSplan.10.WeunderstandthatwemustnotifytheEDDimmediatelyifthereareanychangestotheinformationonthisplanapplication,andthatwemustsubmitthespecificchangesinwritingforreviewandapproval.11.Weunderstandthatleasedortemporaryserviceemployeesthatareprovidedbyanotheremployerorthatweprovidetootheremployers,cannotbecoveredundertheWSplan.12.WeunderstandthatparticipatingintheWSprogramisconsistentwiththeemployer222sobligationunderapplicablefederalandstatelaws. DE8686Rev.(-17 Page3of5 WorkSharing(WS)UnemploymentInsurancePlanApplicationMail:EmploymentDevelopmentDepartmentQuestions?916-464-3343 American LegalNet, Inc. www.FormsWorkFlow.com HOLIDAY OPEN CLOSED COMMENTS NewYear'sEve NewYear'sDay(Observed) MartinLutherKingJr.Day Lincoln'sBirthday Washington'sBirthday President'sDay CesarChavezDay GoodFriday MemorialDay July4th LaborDay ColumbusDay VeteransDay Thanksgiving DayAfterThanksgiving ChristmasEve ChristmasDay(Observed) OtherHolidays:Pleaselistbelow IhaveprovidedtheinformationonthisformsothatouremployeesmayparticipateintheWorkSharingUnemploymentInsuranceprogram.Iunderstandfailuretoprovidecorrectinformation,inaccordancewiththiscertificationandinaccordancewiththeprovisionsoftheCaliforniaUnemploymentInsuranceCode(CUIC),couldresultinadenialorcancellationofthisplan.IcertifythatIagreetoallWorkSharingtermsperSection1279.5oftheCUIC.Ifsigningthisformelectronically,Iunderstandandacknowledgethatthiselectronicsignaturehasthesamemeaningandvalidityasmyhandwrittensignature.IfurtherattestthatIhavesignatureauthoritywiththenamedemployer.*Ifaprivatebusiness,belowsignaturemustbeofcorporateofficer,soleproprietor,orgeneralpartner.*Ifapublicentity,belowsignaturemustbeofexecutiveofficerorpersonwithauthorization.AuthorizedSignature: Title: PrintName: Date: WorkSharingEmployer222sHolidaySchedule Aholidayscheduleisnecessarytoprocessemployee222sWSpayments.Pleaseindicatewhichholidaysyourcompanywasopen/closedduringthe12monthspriortothestartofyourWSplan. DE8686Rev.(-17 Page4of5 WorkSharing(WS)UnemploymentInsurancePlanApplicationMail:EmploymentDevelopmentDepartmentQuestions?916-464-3343 EmployerAccountNumber:226226 PleasecompletetheWSEmployeeParticipantRosteronpage5andensurethenumberofemployeeslistedmatchesthetotalnumberofemployeeslistedonpage1,question7c. American LegalNet, Inc. www.FormsWorkFlow.com Employee222sFullName Employee222sFullSSN Department/WorkUnitName IndicateifWSemployeeisaCorporateOfficerorSoleorMajorstockholder(Yes/No) Ifapplicable,entertitle/roleofCorporateOfficerorSoleorMajorstockholder 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. WorkSharingEmployeeParticipantRoster *EmployeeParticipantRostermustmatchthenumberindicatedonQuestion#7conpage1of5. additionalspaceisneeded.TheWSplancannotbeapprovedwithoutaWSEmployeeParticipantRoster.DE8686Rev.(-17Page5of5 WorkSharing(WS)UnemploymentInsurancePlanApplicationMail:EmploymentDevelopmentDepartmentQuestions?916-464-3343 EmployerAccountNumber:226226 NOTE:Acompletelistofemployeesparticipatingmustbeincludedwithyourapplication.Copythispageif American LegalNet, Inc