Form De 2063 - Employer'S Statement For The Payroll Weekending June 2001
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1
2LAST NAME
FIRST NAME
SOCIAL SECURITY ACCOUNT NO.
EDD USE ONLY
−
−
Interviewer’s Initial
NOTE: Issue a DE 2063 only for the seven-consecutive-day period corresponding to your payroll
AC
week. If you pay your workers less often than once each seven days, you must issue a
_______________
DE 2063 for each calendar week (Sunday through Saturday) of partial unemployment.
PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS.
EMPLOYER’S STATEMENT FOR THE PAYROLL WEEKENDING
Date
1.
Gross earnings (before deductions) were (if there were no earnings, enter Ø)...................................
$
2.
Did this employee report for all work that was available during this payroll week? .............................
(a)
If the answer is “NO” give date(s)
(b)
REASON:
3.
Why is this employee not working full-time? (Check one)
Lay off due to lack of work (includes reduction in hours)
Discharged
Voluntary Quit
4.
Enter the last date this employee performed any work in your employment either on or prior to the payroll weekending
date shown above:
Date:
EMPLOYER CERTIFICATION: I CERTIFY that the amount in Item 1 represents reduced earnings in a week of less than full-
time work because of lack of work except as shown in Item 2.
ENTER
−
YOUR:
(
)
Company Name
Phone Number
Address
City
Zip
−
−
X
Employer Signature
Employer Account Number
DATE ISSUED TO EMPLOYEE
ISSUE THIS FORM IMMEDIATELY AFTER PAYROLL WEEKENDING DATE SHOWN ABOVE
CLAIMANT: You must complete this section. These questions and your answers are for the payroll weekending date(s)
shown on the top of this form.
A.
Was there any reason other than lack of work why you couldn’t have worked full-time
each regular workday that week? ...................................................................................................
(1) If yes, give reason, dates and time you could not work
B.
Did you work for anyone other than your regular employer on any day in that week?
(This includes self-employment.) ....................................................................................................
(1) What is the employer’s name?
Address:
(2) How much did you earn before deductions from that employer whether you were
paid or not?
$
.......................................................................................................................
(3) Dates worked _______ to ______. Reason no longer working
C.
Are you receiving a pension, other than Social Security?
.........................................................
(1) If yes, has there been a change in the amount since you last reported it? ..............................
$
(2) If there has been a change, enter the new gross amount and explain the ..............................
reason for the change
D.
Did you have a change of address or telephone number in that week?..........................................
E.
If you moved, could you have worked if a job had been offered?
Yes
No
Date(s) of move
→
F.
If you want federal income tax withheld for that week, mark this block
CLAIMANT CERTIFICATION: I understand the questions on this form. I know the law provides penalties if I make false statements
or withhold facts to receive benefits; my answers are true and correct. I declare under penalty of perjury that I am a U.S. citizen or
national, or an alien in satisfactory immigration status and permitted to work by the INS.
−
(
)
ENTER YOUR:
X
Signature
Telephone Number
Address
City
Zip
NOTE:
THIS CLAIM IS TIMELY ONLY BY CONTACTING AN EMPLOYMENT DEVELOPMENT OFFICE WITHIN 28 DAYS AFTER
ISSUED TO YOU.
EXCEPTION:
IF YOU KNOW THAT YOU WILL BE TOTALLY UNEMPLOYED IN EXCESS OF TWO CONSECUTIVE WEEKS,
CONTACT YOUR LOCAL EDD OFFICE IMMEDIATELY.
- Versión en español en el dorso -
DE 2063 Rev. 25 (6-01) Notice of Reduced Earnings (INTERNET)
CU
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