DI / DE 7012

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

Mailing Date:
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CED(s):
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Docket Number:
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Conviction Date:
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County/Jurisdiction:
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Notice of Conviction-Related Overpayments

The State Disability Insurance (SDI) Program has established multiple overpayments under your Social Security number due to your criminal conviction for violations of the California Unemployment Insurance Code (CUIC), the California Penal Code, and/or federal statutes. The attached documents give formal notice that Blank Line overpayments have been established. The original overpayment amount is Blank Line , and
‎ $0.00 
in penalties and costs has been assessed. A total of
‎$0.00
 
is now due and payable by you.
Below is an itemization of the amounts you owe.
1. COURT-ORDERED RESTITUTION Blank line 
2. COURT-ORDERED PENALTY $0.00
3. TOTAL COURT-ORDERED RESTITUTION and PENALTY $0.00
Court-ordered restitution and penalty amount (Item 3) must be paid as established by the Court.

In addition to the above Court-ordered amounts, the Employment Development Department (EDD) requires reimbursement as detailed below:

4. REMAINING OVERPAYMENT AMOUNT (After Court-ordered restitution deducted) $0.00
5. EDD ADMINISTRATIVE PENALTY
(30% of original overpayment amount minus penalty ordered by the Court)		 $0.00
6. EDD COSTS (does not include Court costs) Blank line 
7. TOTAL AMOUNT TO BE PAID DIRECTLY TO EDD $0.00
The EDD hereby requires reimbursement of all monies improperly paid to you or paid to other entities or persons as a result of your actions. The remaining overpayment amount, EDD administrative penalty, and EDD costs (ITEMS 4, 5, and 6) are to be paid directly to EDD. Cashier’s checks, personal checks, or money orders must be made payable to EDD and display your Social Security number Do not send cash. A pre-addressed envelope is enclosed.
Mail only payment of Item 7 to:
Cashier – Benefit Recovery
State of California
Employment Development Department
PO Box 826806
Sacramento CA 94206-0001

Departmental Representative

DE 7012 Rev. 1 (7-21) (INTRANET)