DI / DE 1000VP

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

STATE OF CALIFORNIA UNEMPLOYMENT INSURANCE (UI) APPEALS BOARD VOLUNTARY PLAN (VP) APPELLANT APPEAL

Office of Appeals Case No.
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1.
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Appellant Name
2.
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Social Security Number
3.
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Address
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City StateZIP Code
4.
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Appellant Phone Number
5. The undersigned hereby appeals to the Office of Appeals a determination, decision, or notice of overpayment dated Blank Line, for the reasons specified below. Please provide a complete explanation or reasons for filing the appeal.
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IMPORTANT  
6. CAN YOU SPEAK ENGLISH?
If no, provide the other language:
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Dialect:
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Please verify if any party needs an interpreter:
7 Signature of appellant or agent:
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8Date signed:
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Section ‎ 2707.2 of the code requires the appeal to be filed within thirty (30) calendar days from the mailing or personal service of the notice. The thirty (30) calendar-day period may be extended for good cause. Failure to file within thirty (30) calendar days should be explained in item 5 above. This form should be completed and mailed to or filed at any Employment Development Department (EDD) office.
 

FOLLOWING INFORMATION MUST BE COMPLETED BY THE EDD OFFICE RECEIVING THE APPEAL

9 Appeal filed: By mail postmarked Blank Line (attach envelope).
In person by
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(Name of person delivering appeal.)
on
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Date
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EDD Representative
10 Claim on file at
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Location
Field Office No.
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Claim Effective Date
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11 Parties related to the determination and to the appeal:
Respondent
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Name
 
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Phone Number
 
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Address
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City StateZIP Code
Employer
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Name
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Vol. Plan No.
 
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Phone Number
 
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Address
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City StateZIP Code

DE 1000VP (3-18) (INTRANET)