PRIOR 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)  
                                                                       
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10. Will employees affected by the current layoff receive the same payments under      the same company 
   policy described in the prior Wages Notice?           Yes            No 
      If no, please explain the policy and/or payments. 
                                                                                                           
11.  Please provide the following information regarding payments which will be paid to employees affected 
   by the current layoff: 
 
          Type of Payment               Period Covered by           Work Group Eligible to Receive 
                                        Payment (if applicable)                        Payment 
                                           (MM/DD/YY–MM/DD/YY)   
                                                                    
12. Comments: 
                                                                                                           
Employer Representative/Agent: 
 
Name:                                                                                                      
Title:                                                Phone Number: (                )                     
                                                                       (Area Code)     (Phone Number) 
 
Mailing Address (if different than the business address):                                                  
                                                                                                           
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           INSTRUCTIONS FOR PRIOR WAGES NOTICE UPDATE/CORRECTION REQUEST  
 
The Employment Development Department will prepare a Wages Notice based on the information you 
provide. The Department issues a  Wages Notice to reduce the number of calls to employers and to 
promote consistent decisions  from Department staff regarding payments received by unemployment  
insurance (UI) claimants. The Wages Notice will provide Department    staff    with general information 
regarding the post-employment payments and a determination of whether the payments will affect  the 
claimants’ eligibility for UI benefits. 
 
The Department will also mail you a copy of the Wages Notice for your records. 
 
Please follow the instructions carefully: 
 
1.   CALIFORNIA EMPLOYER ACCOUNT NUMBER –  Enter your California state employer account  
    number. 
2.  BUSINESS NAME – Enter the name by which your business   is known. 
3.  OTHER BUSINESS NAMES – Enter other names by which your business is known and which your 
    employees may  report as their employer.  
4.  MAILING ADDRESS – Provide business mailing address. 
5.  PHONE NUMBER – Enter business phone number including area code. 
6.  Enter the number of the Wages Notice that you would like us to correct or update. 
7.  Enter the issue date of the Wages Notice that you would like us to correct or update. 
Section A: Wages Notice Correction 
    Complete this section if you would like to report information you feel needs to be added or corrected 
    on a current Wages Notice. 
8.  Provide specific information regarding the required changes. If appropriate, be sure to include any 
    pertinent dates, eligibility requirements, payment type, amounts, etc. 
 
Section B: Wages Notice Update 
    Complete this section if you are providing information on a more recent layoff and would like us to 
    update a prior Wages Notice. 
9.  If you have different layoff periods list them separately. 
    DATE(S) OF LAYOFF   – Enter the date(s) you laid off or plan to lay off    the employees. If layoffs will 
    occur over a period of time and you do not have specific dates, you may indicate anticipated 
    beginning and ending dates. Example: 02/05/14   06/30/14–       
    NUMBER OF CALIFORNIA EMPLOYEES LAID OFF   –Enter the total number of employees who 
    work in California and who will be laid off during t he period indicated.  
    LOCATION(S) OF AFFECTED JOB SITES IN CALIFORNIA   –Enter the name(s) of the California 
    city/cities where the job site(s) affected by the layoff is (are) located. If several job sites throughout  
    California are affected you may indicate “statewide” rather then listing the individual job sites. 

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10. If there are any additional payments not addressed in the prior     Wages Notice, describe the different 
   payments, basis for payments, eligibility requirements, etc. 
11. List the payments, other         than wages through the last day worked and accrued vacation, that 
   employees affected by the current layoff will receive.  
   TYPE OF PAYMENT   – Enter what the company calls              the payment. 
   PERIOD COVERED BY PAYMENT     – Ifthe payment covers a specific period of time, enter the 
   dates. For example, if you are reporting in-lieu-of-notice pay you would enter   the date through 
   which employees are in receipt of in-lieu-of  notice pay.  
   WORK GROUP ELIGIBLE TO RECEIVE PAYMENT   –Enter the work group that will receive the 
   payment if it is only a specific  group of employees, e.g., assembly line workers, hourly employees,  
   represented employees, etc. If the layoff involves several sites and only employees at some sites 
   will receive the pay, you may enter site location under Work Group. If all employees affected by the 
   layoff will receive the payment, no entry is required. 
12. COMMENTS   –Provide any additional information regarding the payments that you feel is important 
   and can assist the Department in determining if the payments will affect     the employees’ eligibility for 
   UI benefits. 
 
For more information about completing this      form, please call (916) 403-6358 and ask  to speak to a 
representative in the Wages Notice Group. 
 
You may FAX the completed form to (916) 449-2192, or          mail to Employment Development Department, 
UI Integrity and Accounting Division,     MIC 16A, Wages Notice Group, P.O.     Box 2228, Rancho Cordova, 
CA 95741-2228. 
 
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