Confirmation - Claim Filed

10/6/2020 CONFIRMATION - CLAIM FILED
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CONFIRMATION - CLAIM FILED

Last
General Employment Additional
1 2 Employer 3 4 5 Summary 6 Confirmation
Information History Information
Information
EDGAR LOPEZ
Your application for benefits has been submitted. Your confirmation number is: 30957099
Keep this number for your records.
Important: Update your résumé in CalJOBS to avoid a possible delay in your benefits.
It is your responsibility to read the following information.
Pandemic Unemployment Assistance (PUA) EDD Debit Card Reporting Wages

Important Notices You Will Receive from the EDD Work Search Requirement UI Online
Eligibility Determination Interview CalJOBS California Training Benefits
Prior Disqualification or Overpayments Out-of-State Residents Rate Your Experience
Pandemic Unemployment Assistance (PUA)

If you are determined to be eligible for PUA, you will receive a Notice of Pandemic Unemployment Assistance Award (DE 429PUA) and an Employment
Development Department Customer Account Number notice (DE 5614). You may also receive an email welcoming you to UI Online where you can complete your
required certifications for PUA benefits every two weeks. For more information, visit the Pandemic Unemployment Assistance page.
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Important Notices You Will Receive from the EDD
You will receive the following Unemployment Insurance claim materials in the mail by 06/20/2020.
Notice of Unemployment Insurance Claim Filed (DE 1101CLMT): Summarizes the information you provided when you filed your claim. This information will
be considered accurate unless you contact the EDD within 10 days from the date it was mailed. Failure to report accurate information may result in a
disqualification, overpayment, or an overpayment and penalties
Notice of Unemployment Insurance Award (DE 429Z): Indicates your weekly benefit amount and maximum claim amount which are based on wages
reported by your employer(s). Review the award notice for accuracy and contact Unemployment Insurance if the information is inaccurate within 30 days of the
mail date of this notice. This notice also provides instructions on your work search requirements.
Employment Development Department (EDD) Customer Account Number (DE 5614): The EDD Customer Account Number is required to register for UI
Online and may be used instead of your Social Security number when speaking to an EDD representative.
Unemployment Insurance Benefits: What You Need to Know (DE 1275B): A booklet to help you understand the eligibility requirements to receive
Unemployment Insurance benefits.
Continued Claim (DE 4581): To certify for continued benefit payments, you must provide eligibility information to the EDD every two weeks through UI Online,
EDD Tele-Cert, or by mail. For instructions on how to certify for continued benefits, refer to the booklet, Unemployment Insurance Benefits: What You Need to
Know (DE 1275B) or our helpful UI Online videos.
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Eligibility Determination Interview
If additional information is needed or an eligibility issue is identified, a phone interview appointment is scheduled. You will be notified of the date and time by mail.
With UI Online you may view scheduled appointments and reschedule a phone interview appointment to a later date.
If you are not available for your phone interview, a decision will be made based on the available facts, which can result in the delay or denial of your
Unemployment Insurance benefit payments.
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Prior Disqualification or Overpayments
A disqualification or an overpayment on a previous Unemployment Insurance claim may affect your new claim. Refer to the Notice of Determination/Ruling (DE
1080CZ) you received by mail at the time the disqualification was established.
For overpayments, refer to the Notice of Potential Overpayment (DE 1447) you received by mail at the time the overpayment was established.
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EDD Debit Card
The EDD Debit Card from Bank of America is a fast and secure way to get your Unemployment Insurance benefit payments electronically. Because the same EDD
Debit Card is used for all EDD benefit programs and is valid for three years, you should keep your card until it expires.
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Work Search Requirement
You are required to look for work each week, unless instructed otherwise by the EDD. The Notice of Unemployment Insurance Award (DE 429Z) includes your work
search requirement.
https://uio.edd.ca.gov/UIO/Pages/Public/NewClaim/NewClaimConﬁrmation.aspx 1/5
Examples of looking for work include, contact with employers about a job: in-person, by mail, by phone, or online. It also includes searching for jobs: in newspapers,
in other publications, or online.Failure to look for work could result in the delay or denial of your Unemployment Insurance benefit payments.
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CalJOBS
Provide an updated résumé in CalJOBS within 21 days of filing your claim. Your Unemployment Insurance benefit payments may be delayed or denied if you fail to
update your résumé.
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Out-of-State Residents
You must actively seek work and register for job search assistance with the local employment office in your state within 21 days of filing your claim or you may be
denied Unemployment Insurance benefits. Locate the office nearest you online or through your local phone directory.
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Reporting Wages
When certifying for Unemployment Insurance (UI) benefits, you must report your work and gross wages when you worked and earned the wages, not when you
receive your pay.
For UI purposes, a week begins on Sunday and ends the following Saturday. To calculate your total gross wages for each week, multiply your hourly rate of pay by
the total hours you worked from Sunday through the last day you worked that week. For more information, visit How to Report Work and Wages or view our helpful
UI Online videos.
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UI Online
UI Online is a fast, convenient, and secure way for Unemployment Insurance customers to file or reopen their claim, certify for continued benefits, and manage their
claims 24 hours a day, 7 days a week. For added convenience, UI Online Mobile is available for smartphone and tablet users.
To learn more about the features and benefits of UI Online visit the UI Online homepage.
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California Training Benefits
California Training Benefits (CTB) allows eligible Unemployment Insurance customers to further their education, upgrade their skills, and/or learn a new trade to be
more competitive in today’s labor market while receiving Unemployment Insurance benefits.
If approved for CTB, you will be exempt from the requirements to be available for work, actively seek work, and accept work, while you complete your training. You
may also be eligible for additional weeks of benefits while completing training or school. Visit the California Training Benefits page for more information.
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Applicant Information
1. Social Security number (SSN) or EDD Client Number (ECN) *********

1a. Confirm the last 4 digits of your SSN. 7869
1b. Was this Social Security number issued to you or issued on your behalf by the Yes
Social Security Administration?
2. If you have used any other Social Security numbers, list them.
3. Date of Birth 09/07/1992

4. Gender Male
5. Applicant Name
First Name: EDGAR
Middle Initial: A
Last Name: LOPEZ
6. Is this the name that appears on your Social Security card? Yes
7. If you have used any other names, list them.
Driver License or ID Card Information
1. Do you have a state issued Driver License or ID card? No
Prior Claim Information
1. Between 06/11/2018 - 06/10/2020 did you file a claim(s), reopen a claim(s), or collect No
benefits under the Unemployment Insurance (UI), Disability Insurance (DI) or Paid Family
Leave (PFL) program(s)?
Contact Information
1. What is your mailing address?

Location: United States
Number, Street, and Apartment/Unit or PO Box Number: 281 Padua Hills Pl Apt F
City: San Ysidro
State: CA - California
ZIP Code: 92173
2. Is your residence address the same as your mailing address? Yes
3. If you do not live in California, select the name of the county or county-equivalent (for Alameda County, CA
example, parish, borough, census area, independent city, etc.) where you live.
4. Phone Number 6198023864
4a. Phone Type Cell Phone
Citizenship Information
1. Are you a U.S. Citizen or National? Yes
Statistical Information
1. Education Some college or vocational school

2. Are you a Veteran? No
3. What race or ethnic group do you identify with? Hispanic
4. Do you have a disability? No
5. Preferred spoken/written language?
Spoken Language: English
Written Language: English
Last Employer
Employer Name Employer Mailing Address Employer Physical Address

14375 NW SCIENCE PARK DR 14375 NW SCIENCE PARK DR
COLUMBIA BRANDS USA, LLC
PORTLAND, OR 97229 PORTLAND, OR 97229
Last Employer Information
1. What is the first and last name of your immediate supervisor? Sergio Gomez
2. Last Date Worked 03/08/2020
3. Reason No Longer Working.
Important!
Your last employer will be contacted to verify the reason you are no longer working. Providing false information is considered fraud and may result in
penalties.
Separation Category: Laid Off/No Work
Separation Explanation: Related to the coronavirus (COVID-19)
4. If you received, or if you expect to receive, any payments from your very last employer or any other employer other than your regular wages, report the
payment below.
Amount From Date To Date

4a. Holiday Pay
4b. Vacation Pay
4c. Severance Pay
4d. In-Lieu-Of-Notice Pay
4e. Other Pay
Update Employment Information
Did you work for this

Employer Legal Name Doing Business As (DBA)
employer?
COLUMBIA BRANDS USA, LLC COLUMBIA BRANDS USA, LLC Yes
1. Employer Information
Employer Name: COLUMBIA BRANDS USA, LLC
Mailing Address: 14375 NW SCIENCE PARK DR
City: PORTLAND
State: OR
ZIP Code: 97229
2. First day you worked for this employer? 10/24/2019
3. Last day you worked for this employer? 03/08/2020
4. Did you work full time or part time? Part Time
5. How much did you earn per hour?
6. On average how many hours did you work per week? 12
7. Provide wages earned from the employer listed above for the following quarters:
Gross wages earned from 04/01/2020 to 06/30/2020:
Did you work for this

Employer Legal Name Doing Business As (DBA)
employer?
ROSS STORES, INC. ROSS MERCHANDISING, INC. Yes
1. Employer Information
Employer Name: ROSS STORES, INC.
Mailing Address: PO BOX 283
City: ST LOUIS
State: MO
ZIP Code: 63166
2. First day you worked for this employer? 09/05/2019
3. Last day you worked for this employer? 10/31/2019
4. Did you work full time or part time? Part Time
5. How much did you earn per hour? 12
6. On average how many hours did you work per week? 15
7. Provide wages earned from the employer listed above for the following quarters:
Employment History
1. From 01/01/2019 to 03/31/2020, did you work for any other employers not listed above? No
2. From 01/01/2019 to today, which employer did you work for the longest? Columbia
2a. How long did you work for that employer?
Years: 0
Months: 7
2b. Select the industry that best describes this employer. Private Employer
2c. What type of business did that employer operate? (For example: retail furniture Apparel & Accessory Stores
sales, legal services, software manufacturing, road construction, etc.)
2d. What kind of work did you do for that employer? ADMISSION ADVISOR/SALES REP
School Employee Information
1. Did you work for or provide services to or on behalf of any educational institution between No
01/01/2019 to today?
Availability Information
1. What type of work do you normally perform? ADMISSION ADVISOR/SALES REP

2. What other type of work can you perform? CUSTOMER SERVICE
3. Is the type of work you normally perform seasonal? No
4. Do you expect to return to work for a former employer? No
5. Do you have a date to start work? No
6. Are you ready and willing to accept work that matches your work skills and educational Yes
background? (Example: If offered a job, would you be able to accept it?)
7. Are you currently self-employed (have your own business or work as an independent No
contractor) or plan to become self-employed?
8. Are you a member of a union or a non-union trade association? No
Additional Information
1. Are you receiving, or will you receive within the next two weeks, a pension or retirement that No
is not Social Security or Railroad Retirement, which is based on your own work or wages?
2. Are you receiving or do you expect to receive workers' compensation? No
3. Are you currently attending or have a scheduled start date to attend school or training? No
4. Are you now or have you been in the last 18 months an officer of a corporation, officer of a No
union, or the sole or major stockholder of a corporation?
5. Did you serve as elected public official or Governor-exempt appointee in the last 18 months? No
Disaster Information
1. Are you unemployed as a direct result of a recent disaster (for example: COVID-19, Yes
earthquake, flood, mudslide, or fire) in California?
1a. Select the type of disaster. COVID-19
1a.1. What is your annual income for calendar year 2019? If you are a 8483.00
business owner, self-employed, independent contractor or gig worker
provide your net annual income for calendar year 2019.
1a.2. Provide the date your business, employment, or self-employment was 03/14/2020
interrupted as a direct result of COVID-19. For example, the date your
business closed, or the date your hours were reduced, or the date you
were furloughed or placed on leave of absence without pay, or the
date you were going to start work but couldn't due to COVID-19.
1a.3. Select the option for how you were impacted by the COVID-19 Your place of employment is closed as a direct result of
pandemic. COVID-19.
1b. At the time of the disaster, in which county did you reside? San Diego County
1c. At the time of the disaster, in which county did you work? San Diego County
1d. At the time of the disaster, was your unemployment caused by your need to travel No
through a disaster county?
1e. Select the option that best applies to you. Unemployed Worker
1e.1. How many hours did you work per week prior to the disaster? 12
1e.2. Explain briefly how the disaster affected your ability to continue or begin
your self-employment.
1e.3. What is the physical address of your business?
Number and Street:
City:
State:
ZIP Code:
1f. I declare under penalty of perjury that the information I have provided is true and correct to the best of my knowledge or belief, including the reason
I am unemployed due to the COVID-19 pandemic. I understand that intentional misrepresentation in self-certifying that I fall within one or more of
the COVID-19 categories is fraud and that I may be subject to criminal prosecution if I have been found to have committed fraud to receive
Pandemic Unemployment Assistance benefits.
I have read all of the above information.
Certification Preference
Only certify using UI Online or Yes If you select yes, the EDD will not mail the paper continued form (DE 4581) to you. Customers on the Partials or
EDD Tele-CertSM: Work Sharing claims are unable to certify for benefits online at this time but can access the many other features
of UI Online.
Note: It may be necessary to send some documents via U.S. mail.
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Copyright © 2018 State of California

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10/6/2020 CONFIRMATION - CLAIM FILED

CONFIRMATION - CLAIM FILED

It is your responsibility to read the following information.

Pandemic Unemployment Assistance (PUA) EDD Debit Card Reporting Wages

Pandemic Unemployment Assistance (PUA)

1. Social Security number (SSN) or EDD Client Number (ECN) *********

3. Date of Birth 09/07/1992

Driver License or ID Card Information

1. Do you have a state issued Driver License or ID card? No

Prior Claim Information

1. What is your mailing address?

1. Are you a U.S. Citizen or National? Yes

1. Education Some college or vocational school

Employer Name Employer Mailing Address Employer Physical Address

Last Employer Information

Amount From Date To Date

Update Employment Information

Did you work for this

COLUMBIA BRANDS USA, LLC COLUMBIA BRANDS USA, LLC Yes

Did you work for this

ROSS STORES, INC. ROSS MERCHANDISING, INC. Yes

School Employee Information

1. What type of work do you normally perform? ADMISSION ADVISOR/SALES REP

Note: It may be necessary to send some documents via U.S. mail.

Back to Top Contact EDD Conditions of Use Privacy Policy Accessibility

Copyright © 2018 State of California

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