SAMPLE, this page for reference only

RETURN WITH CLAIM FOR DISABILITY INSURANCE BENEFITS, IF ATTACHED; OTHERWISE RETURN IMMEDIATELY.

For faster processing, you may complete and submit this form online at www.edd.ca.gov. If this form is submitted online, you do not have to mail this form back to the Employment Development Department (EDD). When completing this form, PLEASE PRINT WITH BLACK INK.

1. Correct and complete name and address of your employer and the last day worked for this employer.
   1. Blank Line

      Employer's Business Name

      Blank Line

      Employer's Telephone Number
   2. Blank Line

      Employer's Business Address
   3. Blank Line

      City

      Blank Line

      State

      Blank Line

      Zip Code
   4. Blank Line

      Last Day Worked
2. Your occupation with this employer:

   Blank line
3. Your date of birth:

   Blank line
4. Please provide your street address and directions for finding your house. If necessary, draw and attach a map:

DE 5006 Rev. 21 (3-12)