I,_____________________________________________, hereby request a hearing before a hearing official to protest
the Earnings Withholding Order for Taxes of the Employment Development Department, which order affects my salary.
My address is ___________________________________________, ______________________________________,
I understand that an official authorized by the State will notify me of the date and place of the hearing.
I understand that I and my witnesses may give testimony by a phone designated by the Department at departmental
cost and that it is not necessary to appear at the place designated for the hearing if telephone 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 Order is needed for my or my family’s support. A Financial
Declaration must accompany this request. (A Financial Declaration Form is available from the office designated
at the top left portion of the Earnings Withholding Order).
2. All or a portion of the wages subject to the Order is subject to a family support order.
3. All or a portion of the wages subject to the Order is subject to a prior Withholding Order for Taxes.
4. I am not the person for whose tax liability the Order 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 also so that I may understand the
declarations of the hearing official and the testimony of the witness in opposition to my case.
I do not need an interpreter.
-- Versión en español en el dorso --
DE 9401 Rev. 2 (12-02) (INTERNET)
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