DI / DE 5005

SAMPLE, this page for reference only.

EDD Employment Development Department State of California Logo

Mailing Date:
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Claim ID:
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Request for Additional Labor Market Information

 
You recently filed a claim for Disability Insurance (DI) benefits showing the following:
  • The last date you worked was  MM/DD/YYYY
  • The first date you were too sick to work was  MM/DD/YYYY
  • Your doctor began treating you for this  condition  MM/DD/YYYY
Before we can determine your eligibility for Disability Insurance (DI) benefits, we must know if you were either working, seeking work, or registered for work through the Employment Development Department (EDD). Please answer the questions below and return this form WITHIN 10 DAYS of the mailing date shown above. If we do not hear from you in that time, we will use the facts we now have to determine whether or not you are eligible for DI benefits.
 
Telephone:
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  1. If the dates shown in the box above are NOT CORRECT, please correct them.
  2. List your most recent efforts to find work, if any:
    1. Employers Complete Addresses Telephone Numbers Dates Contacted
      (1)Blank space Blank space Blank space Blank space
      (2)Blank space Blank space Blank space Blank space
      (3)Blank space Blank space Blank space Blank space
    2. Union Name
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      Local Number
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      City
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    3. Date registered with EDD (CalJOBS)
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  3. If you have not been looking for work, please explain why:
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  4. Please provide your daytime telephone number in the event we need to contact you:
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I certify under penalty of perjury that the foregoing is true and correct.

Signature of Claimant:
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Date Signed:
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DE 5005 Rev. 19 (4-21) (INTRANET)