LO, << — ak wing tHall! © EDD 3. ress 5 SISTESI California AFFIDAVIT OF WAGES 23A03: 165677630 Maiing Dat: 17242000 For Otte Use Oni Sorts Case Number: 0006 EDD Integrity and Accounting Division LOUIE VALENTINE PO BOX 989152 3135 ROADRUNNER RD West Sacramento, CA 95798-9152 SAN MARCOS CA 92078-6141 Phone: (916) 403-6484 Fax: (916) 449-1564 Bo adaos tlie for an Unemployment insurance (UI) or Disabilty Insurance (0) claim and requested wages 0 Pe.2ided to your claim award. The Employment Development Department (EDD) wil atempl io cad wages based un information that is obiaine our enapioyer. mation is received from your EDD will review wage information you provide and add wages, as appropriate Flease Provide proof of wages paid by Mojica and Sons, and complete sections A through H below. Attach and the dato worgeandlor check stubs on an 8 % x 14 inch sheet of paper that include the amount of earnings foun MUST ae kes. Every sheet submitted to EDD must include your name and social secutiy ruvsber The Sim MUST be completed and returned with your proof of eamings to the EDD address, or fax te the norrber shown above by 11/03/2022 Fr addtional information, review the information on the back of this form or contact us atthe number listed above. A. Employer Name: B. Employer Telephone Number:( C. Employer Street Address: Gily, State, and ZIP Code: D. Physical work location if different E. Type of work performed: F. Dates worked between 07/01/2021 and 06/30/2022 G. Gross wages paid $ How Paid Hourly __Weekly __Bi-weekly __Monthly H. Information included: __Check Stubs __W-2 Form __ Payroll Information __Other creesstand the law provides penalties if| make false statements oF withhold facts to receive benefits. 1 cnderstand wage determinations based on the affidavit are not final: that wage determinations sx subject to sojoclod onthe tne receipt of wage information from the employer, that benefit payments may Rave tec Sree on tne basis of the information from the employer, and that any amount overpaid mey have ee repaid Cr set against future benefits. | declare the information provided is true and correct to the beat of my Knowledge. Your signature is required. Your benefits may be delayed or denied if tis form is hot signed. Signature of Claimant Date 562165677630 0006200716 DE 234 Rev. 4 (3-22) iliac anda CT cu