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Form De 9401 - Hearing Request Form - Employment Development Department English-Spanish Version

Hearing Request

I, _____________________________________________, hereby request a hearing before a hearing official to protest the

Earnings Withholding Order for Taxes (EWOT) (DE 9400) of the Employment Development Department (EDD), which order

affects my salary.

My address is ______________________________________________, ______________________________________,

Number

Street

City

____________________________, ________________________________________________.

County

State

ZIP Code

I understand that an official authorized by the state will notify me of the date and place of the hearing.

I understand that my witnesses and I may give testimony by a phone designated by the EDD at departmental cost and that it is

not necessary to appear at the place designated for the hearing if phone testimony is provided.

The reason(s) for my request for a hearing is (are) the following:

Mark the appropriate reason(s):



1. All or a portion of the wages subject to the EWOT is needed for my family or my support. A Combined Statement of

Financial Condition and Income and Expense Declaration (DE 9406) must accompany this request. (The DE 9406 is

available from the office designated at the top left portion of the EWOT).



2. All or a portion of the wages subject to the EWOT is subject to a family support order.



3. All or a portion of the wages subject to the EWOT is subject to a prior Withholding Order for Taxes.



4. I am not the person for whose tax liability the EWOT was issued.



5. Other reasons are _____________________________________________________________________________________

____________________________________________________________________________________________________

Mark one of the following blocks:



I request a qualified interpreter certified by the State of California in order that the hearing official may understand

and comprehend my testimony and that of my witnesses and so that I may also understand the declarations of the

hearing official and the testimony of the witness in opposition to my case.



I do not need an interpreter.

________________________________________________

Date

Signature

-- Versión en español en el dorso --

DE 9401 Rev. 3 (5-15) (INTERNET)

Form De 9401 - Hearing Request Form - Employment Development Department English-Spanish Version