Form De 4809 - Prior Wages Notice Correction/update Request
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2PRIOR WAGES NOTICE CORRECTION/UPDATE REQUEST
1. California Employer Account Number: ____________________________________________________
(8 Digit Code)
2. Business Name:______________________________________________________________________
3. Other Business Names:________________________________________________________________
4. Mailing Address: _____________________________________________________________________
(Address)
___________________________________________________________________________________
(City)
(State)
(Zip Code)
5. Phone Number: (_____) _______________________________________________________________
(Area Code)
(Phone Number)
6. Prior Wages Notice Number : ___________________________________________________________
7. Date of Prior Wages Notice: ____________________________________________________________
Complete Section A if you are reporting a correction required on a current Wages Notice.
Complete Section B if you need to update a prior Wages Notice to reflect a more recent layoff.
Section A: Wages Notice Correction
8. Please explain what corrections are necessary to the Wages Notice.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Section B: Wages Notice Update
9. Please provide the following information regarding the current layoff:
Date(s) of Layoff
Number of California
Location(s) of Affected Job Sites
Employees Laid Off
in California
(MM/DD/YY–MM/DD/YY)
(City)
DE 4809 Rev. 2 (12-02) (INTERNET)
Page 1 of 4
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