DI / DE 1000AA

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

APPEAL FORM

DO NOT RETURN THIS FORM UNLESS YOU WANT TO APPEAL THE ENCLOSED NOTICE OF DETERMINATION

As shown on the enclosed notice of determination, you are not eligible for all or part of the period claimed. To appeal this decision to an administrative law judge, please explain why you disagree with the decision, and return this form to the address above. You must return this form by the appeal deadline timeframe specified on the enclosed notice of determination. The appeal period may be extended for good cause. If your appeal is late, state the reason you are filling late.
I disagree with the decision contained in the notice datedBlank line The reason(s) I disagree is:
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(Attach an additional sheet if more space is required)
While your appeal is pending, you must complete and return a claim certification for the period(s) that you want to claim benefits. If you are found eligible, you will only be paid benefits for periods for which you file a claim certification and meet all other eligibility requirements.
Is English your preferred language?
If no, provide your preferred language and dialect: ____________________________Blank line
SSN: Blank line - Blank line - Blank line
Name: Blank line
Phone: Blank line
Mailing Address:
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Street No., Apt No., or PO Box
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City
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State
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ZIP Code
Signature of Appellant or Agent:
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Date:
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Your mailing address, if different than above; or your Agent's address: (if applicable)
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FOR DEPARTMENT USE ONLY
EDD VERIFIES THAT PARTY NEEDS INTERPRETER

DE 1000AA Rev. 2 (8-21) (INTRANET)