DI / DE 6341

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

For Dept. Use Only Effective -
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REVOCATION OF RELIGIOUS EXEMPTION CERTIFICATE

(Employee must complete the statement below. Please print.)

Your Name
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Social Security number
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Your Address
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Street Number
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City
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State
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ZIP Code
* Employer's Business Name
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* Employer's Account Number
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Employer’s Address
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Street Number
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City
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State
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ZIP Code

In accordance with the provisions of California Unemployment Insurance Code (CUIC), section 2902, I hereby revoke the Religious Exemption Certificate (DE 5067) filed with the Employment Development Department (EDD) and the above employer.

Effective Date (Check One)

Date
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Signature of Employee
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Instructions

Send two copies of this certificate to:

Employment Development Department Disability Insurance Branch PO Box 826880 Sacramento, CA 94280-0001

The Department will send one copy, showing the effective date, to your employer.

* EMPLOYER’S BUSINESS NAME – If you don’t know the name under which your employer is doing business, ask them.

* EMPLOYER’S ACCOUNT NUMBER – This is the number your employer uses to pay their unemployment insurance (UI) contributions. Ask them for this number.

DE 6341 Rev. 2 (9-21) (INTRANET)