Form DE1101IBD "Unemployment Insurance Application (Federal Employee)" - California

What Is Form DE1101IBD?

This is a legal form that was released by the California Employment Development Department - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2014;
  • The latest edition provided by the California Employment Development Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DE1101IBD by clicking the link below or browse more documents and templates provided by the California Employment Development Department.

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Download Form DE1101IBD "Unemployment Insurance Application (Federal Employee)" - California

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1101I01BD
1114
UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee)
FILING INSTRUCTIONS
Complete this application including any applicable attachment(s). Print or type the information. Use blue or black ink only.
Answer all questions on each page. Review your application thoroughly for completeness. An incomplete application may delay
or prevent the filing of your claim, or cause benefits to be denied. If the Employment Development Department (EDD) needs to
verify any of the information you provide while filing a claim, you will receive additional forms by mail and will be asked to provide
additional information and/or documentation.
APPLICATION QUESTIONS
The answers you give to the questions on this application must be true and correct. You may be subject to penalties if you make a
false statement or withhold information.
1.
Did you work in a state other than California during the
1.
Yes
No
If yes, check the applicable box(es) below:
last 18 months?
State(s) Outside California, specify state(s):
AND / OR
Canada
Did you work in Canada during the last 18 months?
2.
What is your Social Security number as given to you
2.
by the Social Security Administration?
-
-
a)
If the EDD assigned you an EDD Client Number
a)
(ECN), please provide the ECN here. (An ECN is a
-
-
9-digit number beginning with 999 or 990.)
2A. List any other Social Security numbers you have used.
2A.
-
-
-
-
3.
What is your full name?
3.
Last
First
Middle Initial
4.
Is this the name that appears on your Social Security
4.
Yes
No
card?
a)
Last
a)
If no, provide the name that appears on your
Social Security card.
First
Middle Initial
5.
List any other names you have used.
5.
6.
What is your birth date?
6.
(mm/dd/yyyy)
7.
What is your gender?
7.
Male
Female
8.
Would you prefer your written material in English or
8.
English
Spanish
Spanish?
a)
What is your preferred spoken language?
a)
9.
Have you filed a California Unemployment Insurance
9.
Yes
No
or a Disability Insurance claim in the last two years?
a)
If yes, list each type of claim and the most recent
a) Unemployment Claim Date(s) (mm/dd/yyyy)
date(s) of when the claim(s) was filed.
a) Disability Claim Date(s) (mm/dd/yyyy)
DE 1101IBD Rev. 4 (11-14) (INTERNET)
Page 1 of 13
CU
1101I01BD
1114
UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee)
FILING INSTRUCTIONS
Complete this application including any applicable attachment(s). Print or type the information. Use blue or black ink only.
Answer all questions on each page. Review your application thoroughly for completeness. An incomplete application may delay
or prevent the filing of your claim, or cause benefits to be denied. If the Employment Development Department (EDD) needs to
verify any of the information you provide while filing a claim, you will receive additional forms by mail and will be asked to provide
additional information and/or documentation.
APPLICATION QUESTIONS
The answers you give to the questions on this application must be true and correct. You may be subject to penalties if you make a
false statement or withhold information.
1.
Did you work in a state other than California during the
1.
Yes
No
If yes, check the applicable box(es) below:
last 18 months?
State(s) Outside California, specify state(s):
AND / OR
Canada
Did you work in Canada during the last 18 months?
2.
What is your Social Security number as given to you
2.
by the Social Security Administration?
-
-
a)
If the EDD assigned you an EDD Client Number
a)
(ECN), please provide the ECN here. (An ECN is a
-
-
9-digit number beginning with 999 or 990.)
2A. List any other Social Security numbers you have used.
2A.
-
-
-
-
3.
What is your full name?
3.
Last
First
Middle Initial
4.
Is this the name that appears on your Social Security
4.
Yes
No
card?
a)
Last
a)
If no, provide the name that appears on your
Social Security card.
First
Middle Initial
5.
List any other names you have used.
5.
6.
What is your birth date?
6.
(mm/dd/yyyy)
7.
What is your gender?
7.
Male
Female
8.
Would you prefer your written material in English or
8.
English
Spanish
Spanish?
a)
What is your preferred spoken language?
a)
9.
Have you filed a California Unemployment Insurance
9.
Yes
No
or a Disability Insurance claim in the last two years?
a)
If yes, list each type of claim and the most recent
a) Unemployment Claim Date(s) (mm/dd/yyyy)
date(s) of when the claim(s) was filed.
a) Disability Claim Date(s) (mm/dd/yyyy)
DE 1101IBD Rev. 4 (11-14) (INTERNET)
Page 1 of 13
CU
1101I02
UNEMPLOYMENT INSURANCE APPLICATION
Social Security number:
10. Do you have a Driver License issued to you by a
10.
Yes
No
State/entity?
a)
If yes, provide the name of the issuing State/entity
a)
Name of issuing State/entity:
and your Driver License number.
Driver License Number:
If no, answer questions b-d:
If no, answer questions b-d:
b)
Yes
No
b)
Do you have an Identification Card issued to you
by a State/entity?
c)
Name of issuing State/entity:
c)
If yes, provide the name of the issuing State/entity
and your Identification Card number.
Identification Card Number:
d)
Please Explain:
d)
How do you look for work and, if you have work,
how do you get to work?
11. What is your telephone number?
11.
a)
If you are deaf, hard of hearing, or have a speech
a)
TTY (Non-voice)
California Relay Service
disability and use TTY or California Relay to
communicate, check the appropriate box.
12. What is your mailing address?
12. Street:
Apt.:
(Include your city, State, and ZIP code)
City:
State:
ZIP Code:
13. Is your residence address the same as your mailing
13.
Yes
No
address?
a)
Street:
Apt.:
a)
If no, enter your residence address. (Include your
city, State, ZIP code and apartment number.)
City:
A residence address cannot be a P.O. Box. Please
State:
ZIP Code:
provide a street address.
14. If you do not live in California, what is the name of the
14.
County in which you live?
15. What race or ethnic group do you identify with? Check one of the following:
White
Black not Hispanic
Hispanic
Asian
American Indian/Alaskan Native
Chinese
Cambodian
Filipino
Other Pacific Islander
Guamanian
Asian Indian
Japanese
Korean
Laotian
Samoan
Vietnamese
Hawaiian
I choose not to answer
16. Do you have a disability? (A disability is a physical or
16.
Yes
No
I choose not to answer
mental impairment that substantially limits one or more
life activities, such as caring for oneself, performing
manual tasks, walking, seeing, hearing, speaking,
breathing, learning, or working.)
17. What is the highest grade of school you have completed? Check only one box.
Did not complete High School
High School Diploma or GED
Some college or vocational school
Associate of Arts
Bachelor of Arts or Science
Masters or Doctorate
18. Are you a Military Veteran?
18.
Yes
No
DE 1101IBD Rev. 4 (11-14) (INTERNET)
Page 2 of 13
1101I03
UNEMPLOYMENT INSURANCE APPLICATION
Social Security number:
19. Provide your employment and wages information for the past 18 months. If you worked for a temporary agency, a labor contractor, an
agent for actors or actresses, or an employer where wages are reported under a corporate name, your wages may have been reported
under that employer name. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer.
a)
Name and mailing address of all employers you worked for in the last 18 months.
b)
Period of employment (Dates Worked).
c)
Total Wages earned for each employer in the last 18 months.
d)
How you were paid (specify hourly, weekly, monthly, annually, commission, or at piece rate).
e)
Specify if you worked full-time or part-time.
f)
How many hours you worked per week.
g)
Check the appropriate “Yes/No” box if the employer is (or is not) a school or educational institution or a public or nonprofit employer
where you performed school-related work.
NOTE: It is important that you report the employer name(s) and mailing address(es), period(s) of employment, and wages correctly. Failure to
provide complete information will result in your benefits being delayed or denied.
a)
Employer Name and Mailing Address
b) Dates Worked
c) Total Wages
d) How were you paid?
(e.g.,weekly, monthly, etc.)?
Name:
From:
$
Mailing Address:
To:
Street:
City:
State:
ZIP Code:
e)
Did you work full-time or part-time?
F/T
P/T
f) How many hours did you work per week?
g)
Is this employer a school employer or a public or nonprofit employer where you performed school-related work?
Yes
No
If yes, provide phone number:
a)
Employer Name and Mailing Address
b) Dates Worked
c) Total Wages
d) How were you paid?
(e.g.,weekly, monthly, etc.)?
Name:
From:
$
Mailing Address:
To:
Street:
City:
State:
ZIP Code:
e)
Did you work full-time or part-time?
F/T
P/T
f) How many hours did you work per week?
g)
Is this employer a school employer or a public or nonprofit employer where you performed school-related work?
Yes
No
If yes, provide phone number:
a)
Employer Name and Mailing Address
b) Dates Worked
c) Total Wages
d) How were you paid?
(e.g.,weekly, monthly, etc.)?
Name:
From:
$
Mailing Address:
To:
Street:
City:
State:
ZIP Code:
e)
Did you work full-time or part-time?
F/T
P/T
f) How many hours did you work per week?
g)
Is this employer a school employer or a public or nonprofit employer where you performed school-related work?
Yes
No
If yes, provide phone number:
a)
Employer Name and Mailing Address
b) Dates Worked
c) Total Wages
d) How were you paid?
(e.g.,weekly, monthly, etc.)?
Name:
From:
$
Mailing Address:
To:
Street:
City:
State:
ZIP Code:
e)
Did you work full-time or part-time?
F/T
P/T
f) How many hours did you work per week?
g)
Is this employer a school employer or a public or nonprofit employer where you performed school-related work?
Yes
No
If yes, provide phone number:
DE 1101IBD Rev. 4 (11-14) (INTERNET)
Page 3 of 13
1101I04
UNEMPLOYMENT INSURANCE APPLICATION
Social Security number:
19. Continued
a)
Employer Name and Mailing Address
b) Dates Worked
c) Total Wages
d) How were you paid?
(e.g.,weekly, monthly, etc.)?
Name:
From:
$
Mailing Address:
To:
Street:
City:
State:
ZIP Code:
e)
Did you work full-time or part-time?
F/T
P/T
f) How many hours did you work per week?
g)
Is this employer a school employer or a public or nonprofit employer where you performed school-related work?
Yes
No
If yes, provide phone number:
a)
Employer Name and Mailing Address
b) Dates Worked
c) Total Wages
d) How were you paid?
(e.g.,weekly, monthly, etc.)?
Name:
From:
$
Mailing Address:
To:
Street:
City:
State:
ZIP Code:
e)
Did you work full-time or part-time?
F/T
P/T
f) How many hours did you work per week?
g)
Is this employer a school employer or a public or nonprofit employer where you performed school-related work?
Yes
No
If yes, provide phone number:
20. During the past 18 months did you work for any other
20
Yes
No
employers not listed in question 19?
If yes, list the employer information for questions 19 a-g on a separate sheet of
paper. Attach the additional sheet of paper to this application.
21. If the EDD finds that you do not have sufficient wages
21
Yes
No
in the Standard Base Period to establish a valid claim,
do you want to attempt to establish a claim using the
Alternate Base Period?
For additional information about the Standard Base
Period and the Alternate Base Period, visit the EDD
website www.edd.ca.gov.
22. During the past 18 months, which employer did you
22. Employer name:
work for the longest?
a)
What type of business was operated by the
a) Type of business:
employer? (Please be specific. For example,
restaurant, dry cleaning, construction, book store.)
b)
How long did you work for that employer?
b) Years:
Months:
c)
What type of work did you do for that employer?
c)
23. What is your usual occupation?
23.
24. Is your usual work seasonal?
24.
Yes
No
If yes, answer questions a-c:
If yes, answer questions a-c:
a)
When does the season usually begin?
a)
(mm/dd/yyyy)
b)
When does the season usually end?
b)
(mm/dd/yyyy)
c)
What other work-related skills do you have?
c)
DE 1101IBD Rev. 4 (11-14) (INTERNET)
Page 4 of 13
1101I05
UNEMPLOYMENT INSURANCE APPLICATION
Social Security number:
Please provide information about your very last employer. This is the employer you last worked for regardless of the length of
time you worked at that job, the type of work you did for that employer, or whether or not you have been paid.
If you worked for a temporary agency, a labor contractor, an agent for actors or actresses, or an employer where wages are
reported under a corporate name, your wages may have been reported under that employer name. If you worked for In-Home
Supportive Services (IHSS), the welfare recipient for whom you provided the in-home supportive service is your employer, not
the county. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer.
Reminder: To file a claim, individuals must be out of work or working less than full time. You must provide information about the
last employer you worked for as an employee. Do not include self-employment unless you have elective coverage.
25. What is the last date you actually worked for your very
25.
(mm/dd/yyyy)
last employer?
a)
What are your gross wages for your last week of
a)
$
work? For Unemployment Insurance purposes, a
week begins on Sunday and ends the following
Saturday.
b)
What is the complete name of your very last
b)
Name:
employer?
c)
What is the mailing address of your very last
c)
Mailing address:
employer?
Street:
City:
State:
ZIP Code:
d)
Yes
No
d)
Is the physical address of your very last employer
the same as their mailing address? (A physical
address cannot be a P.O. Box. Please provide a
street address.)
Physical address:
If no, what is the physical address of your very
last employer?
Street:
City:
State:
ZIP Code:
e)
What is the telephone number of your very last
e)
employer at their physical address?
f)
What is the name of your immediate supervisor?
f)
g)
Briefly explain in your own words the reason
g)
Reason:
you are no longer working for your very last
employer, within the space provided. Please do
not include any attachments.
26. Are you (directly or indirectly) out of work with any
26.
Yes
No
employer (last employer or any employer in the last
18 months) due to a trade dispute, such as a strike or
a lockout?
If yes and a union was/is involved, answer
If yes and a union was not/is not involved, answer questions c-e:
questions a-b:
a)
What is the name and telephone number of the
c)
How many employees left work?
union?
d)
Was there a spokesperson for the employees?
Yes
No
Name:
e)
If yes, what is his/her name and telephone number?
Phone:
Name:
Phone:
b)
Are you going to receive strike benefits?
Yes
No
DE 1101IBD Rev. 4 (11-14) (INTERNET)
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