Initial Claim and Payment Certification

Mail to: Special Claims Office, PO Box 419076, Rancho Cordova, CA 95741-9076
Questions? 1-916-464-3300
Work Sharing Employer:
 Complete Section A - Employer’s Information and Certification.

 Instructions for completion of this form are contained in the Guide for Work Sharing Employers, DE 8684.
 This form must be issued to the employee for the first Work Sharing week within 14 calendar days after the Week Ending date
shown below.
 If your payroll period is other than weekly, the WEEK ENDING date must be a Saturday.

Work Sharing Employee:

 Complete Section B - Employee Certification and Section C - Employee Information.
 Mail completed form within 14 calendar days of the date your employer issued it.

Section A – Employer’s Information and Certification

Last Name First Name Social Security Number

Jones David 357886521

Employer’s Certification for the WEEK ENDING date: 09/19/2020

Normal Total % of Wages 50.0 % %

$1,000.00 $500.00
Weekly Wages $ Wages Paid Reduced Due to WS

Normal Weekly 40.00 Total 20.00 % of Hours 50.0 %

Hours Hours Worked Reduced Due to WS

1.  Yes  No During the week above, was the employee absent from work for reasons other than Work Sharing?
If yes, complete the table below.
Date 09/17/2020

Absence Yes
Approved?
Hours Absent 8.00
Reason for Sick
Absence
2.  Yes  No Did the employee refuse any work?
Date 09/16/2020

Number of 4.00
Hours Refused
Reason for Out of town
Refusal
3. Enter the date(s) and hour(s) used for Work Sharing reductions during this week:
Date 09/18/2020
Number of Hours 8.00
Reduced

I certify the above information concerning the status of this company and the status/earnings of this employee for the purposes of participating in the
Work Sharing program is true and correct. At least two employees, and not less than 10 percent, of the regular permanent work force, involved in the
affected work unit(s), participated in the Work Sharing program, or in at least one week of a consecutive two-week period. This company will
maintain employees’ health and retirement benefits under the same terms and conditions as prior to the reduction in hours and wages or to the same
extent as other employees not participating in the Work Sharing plan pursuant to the California Unemployment Insurance Code Section, 1279.5
(c)(4)(A).

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 I understand and acknowledge that this electronic signature has the same meaning and validity as my handwritten signature. I further attest that I
have signature authority with the named employer. 

Company Name Title Employer Account Number

Sam's Smoothies Owner 652-3589-1
Printed Name of Signee Employer Phone Number
Complete Address Sam Smith 916-391-7064
987 Broadway
Sacramento, CA 95814 Employer Signature Date Issued to Employee
10/01/2020

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 Section B – Employee’s Certification: Answer the following questions for the week of [09/13/2020] - [09/19/2020].

Other Employer Information

1.  Yes  No Did you work for anyone other than your Work Sharing employer during the week of [09/13/2020] - [09/19/2020]?

Name Address Last Date Total Earnings* Are you still Reason you no Explain why
Worked working for this longer work for you no longer
employer? this employer. work for this
employer.
McDonalds 12 Z St Carson 09/13/2020 $400.00  Yes  No Fired or I got fired.
City, AR 95608 Discharged

*Note: Enter total earnings before deductions, whether you were paid or not.

2. Do you want federal income tax withheld for the week of [09/13/2020] - [09/19/2020]?  Yes  No

Section C – Employee Information: Provide the following information to file your Work Sharing claim.
First Name Last Name Middle Initial
David Jones
Social Security Number Birth Date Gender
357886521 03/20/1991  Male  Female
1.  Yes  No Is the name used on this form the same as the one that appears on your Social Security card?
Last: Jones First: William M.I.:
a. List any other names you have used:
Will Jones, David Jones
b. List any other Social Security numbers you have used:
111-78-7896, 127-45-7874
2. Mailing Address: 12 D St Unit/Apt:
City: Moreno ZIP Code: 95608 Phone: 991-457-7878
a.  Yes  No Is your residence address the same as your mailing address? If no, enter your residence address.
NOTE: A Post Office Box is not a residence address.
Street Address: 12 C St Unit/ Apt:
City: San Diego State: AL - Alabama ZIP Code: 99951
3.  Yes  No In the past two years, have you filed an Unemployment Insurance, Work Sharing, or Disability Insurance claim in
the State of California?
List the type of claim filed and the date when the claim was filed.
Unemployment Insurance 10/03/1999 Unemployment 07/12/2020
Insurance

4.  Yes  No In the last 18 months, did you work for an agency of the federal government or serve in the military?
5.  Yes  No In the past 18 months, did you work in a state other than California?
List the other states you worked in:
Utah, AZ

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 6.  Yes  No In the past 12 months, did you apply for Unemployment Insurance benefits in another state?
List the other states where you applied for benefits:
CO, UT, AZ
7.  Yes  No Do you have a driver’s license or I.D. card? If yes, complete portion below:
Issuing State: AL - Alabama
Driver License/ID number: B7545121

8.  Yes  No Are you a U.S. citizen or national? If no, complete a, b, c and d.

a.  Yes  No Are you registered with the United States Citizenship and Immigration Services
and authorized to work in the United States?

b. Select the type of United States Citizenship and Immigration Services document:
 Permanent Resident Card (I-551)  Temporary Resident Card (I-688)  Arrival/Departure Record (I-94)
 Employment Authorization Card (I-766)  Other: B4121
c. USCIS/A# number: AS458451 Expiration Date: 10/24/2021
d.  Yes  No Were you legally entitled to work in the United States for the last 19 months?

9.  Yes  No Are you receiving or will you receive a pension in the next year, other than Social Security, which is
based on your own work and wages? If yes, complete a, b, c and d.
a. Who pays the pension check to you? Big Lots
b. How are you receiving your payments?  Monthly  Annually  Single Installment
c.  Yes  No Did you pay into your pension or retirement?
d.  Yes  No Did an employer you worked for in the past 18 months pay into your pension fund?
If yes, what is the name of the employer? Big Lots
Pension Amount: $20,000

10. List the employers you worked for in the past 18 months. Include earnings, how often you were paid, and dates worked.
Employer Name Earnings Pay Cycle Dates Worked
McDonalds $20,000.00 Weekly 10/03/2019

11. Which employer did you work for the longest? Big Lots
a. What type of business does that employer do? Construction
b. What type of work did you do for this employer? Building Construction General Contractors & Operative Builder
c. How long did you work for this employer? 12 years

12.  Yes  No Are you now, or have you been in the past 18 months, an officer of a corporation or the sole or major
stockholder of a corporation?

13.  Yes  No Are you receiving or do you expect to receive workers’ compensation? If yes, fill in information below.
Name of Insurance Carrier: State Farm
Case Number: A4512135GH
Amount of worker’s compensation payment: $2,000

14. Written language preference:  English  Spanish

15. Spoken language preference:  English  Spanish  Other French

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 The following questions are optional:
What race or ethnic group do you identify with? ______________  I choose not to answer

Do you have a disability?  Yes  No  I choose not to answer

I do hereby claim benefits. I am a Work Sharing employee working reduced hours. The information provided above is true and
correct to the best of my knowledge and belief. Pertaining to Question 8, citizenship status, I declare under Penalty of Perjury,
under the laws of the State of California, that my answer is true and correct. I understand the law provides a fine and/or
imprisonment for making false statements or withholding facts to fraudulently receive Unemployment Insurance benefits. I
understand when submitting my request for benefits my submission is considered the same as my signature.

You must indicate your acceptance of the statement by checking the box before your certification can be submitted. 
Name Date Submitted
David Jones 10/01/2020

Note: Date signed must be On or After the date issued by the

employer.

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