Free Declaration in Support - District Court of California - California

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DISABILITY INSURANCE A Department
_ POBOX10l•02 State of California -.
_ vita ttuvs ct sttrto-choz (890) A80- 3287 V - - ‘ yi
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RETURN T0 ····· > DISABILITY INSURANCE yi
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VAN NUYS CA 9I lr I 0*0 #02
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KAI SER PERHANENTE `N .@M6 0% MMWETTT · A
280 H HCARTHUR BLVD II employer name and/or address differs from *
OAKLAND CA 9l•6I‘l MR 1 3 that shown at left, please correct here;
.;; ——————-
NOTICE TO EMPLOYER OF STATE DISABILITY CLAIM FILED
____ , - _ . . ._ lnf¤rm:.tti¤rt.is.requirerl.to.detcrminc thccmplozrccls el? ibility for ... -. 11*
State Disability lnsura nce benefits, a worker- inancetfprogram.
lf the ernplo ee shown below is NOT your employee please check this box l
and return this form IMMEDIATELY ..- ......................... .............. s...- .........................,.__,,,.,,___,___,,_,_,____,____,__________ _ ______ _______ ______________ [Il __
REPORTED LAST CLAIM
EMPLOYEE‘S NAME BADGE NO. SSN DAY AT WORK EFFECTIVE DATE ECN MAILING DATE
··· *¤$· 1 an
V FERNANDO M 572·49·5486 O1-24-06 q3-g2-gg
Section 2707.1 ofthe California Unemployment Insurance Code requires that you complete and return this form I
within two working days if your answer to any of the questions is 'YE.' g
1, Du your reeurds show a different last day at work than shown above? ___________________ _ __________________________ ___________ _____ __ _____ E:] Ye, [;| Nu
tf YES, provide correct last day at work: _ gf
2, Did ihe employee wort las than a normal scheduled work day on his/her last day at work? ,___,,,,_ __,,___,,_,, _ __,__, Q Yes I;] No V
lf YES, { hours worked at S 1,; per hour.
3, Has the employee returned to work? ....... i ...................................................................,......,. , .,.. 1 .,_,,,__,,_________,_______________ ____ ____ E Ye.s I:] Ng
lf YES, date retumed to work: ..;_____i1_ lj full-time I:] part—time
4, Did the employee stop work for any reason other than illness, iniury, nr pregnancy? ___________________________________v__________ Q yes C] No
lf YES, state reason: . ' ’ ’ Q
S, Has the employee received or will the employee receive wage (excluding vacation pay) in the lorm of ‘ I3)
paid sick leave, personal time off, or other type of payment while disabled? (lf the employee's wages
will be reduced by the amount uf State Disability Insurance paid, please amwer 'NO.') __________________________________ El yes Q No
I _ tt YES: a. Wagedsick leave: From: to . Amount S
i b. what was the employee's regular weekly rate of pay or eamings prior to disability `
(excluding overtime)? S y
6. At the time the empIoyee's disability began, did you have a stateappruved voluntary plan for
disability insurance benefits instead of the state plan? .... [ ,..,,.,,.,..,.,,,.,,....,.............. -..-... .................,.. _ ..........,,......,.,_____ Q YQ! C) Nu Y]
lf YES: a. Enter the plan number: 99- _____ _ ‘
b. lf employee is not covered, give reason:
7. Has the employee reported a wurlcincuned injury or occupational illness? ......................:............................ . .,......... [3 YE K:] No U1 '
tf YES: a. Enter name, addrus, and phone number of your worlters' compensation carrier: `I
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b. Emer employee’s 'date of iniury": I jj
- 8, Completed by (Sign and Print Name): Date: _ Phone Number: •°
y , K ` to I
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A Do not return this form tf answers to all ofthe above questions are 'N0.' UT
an ~ . Q
-7 _____r___Tv__ __ M____,_ V __ ____ _ _____ _T__i_____,__f_________ ; ’ ________,______f__........._......-;-;..-.—. .»%,L....4.».» -»·..-w---»»·—r—-j%·——-—— ——·i»——-—» »-——-· W 2;;:
A DFLYSUFI Rev. .i (8-GS) CU—PA79Q ·:~§-;
K0042l °`f

Case 3:07-cv—O3114-SI Document 48-18 Filed O9/O5/2008 Page 2 of 4 _ J
Apr—25-2006 05:03pm From-KAI SER HUMAN RESOURCES SIU 873 5039 · T-492 P. DUI/UUI F-BIB y
Northem Califomia
KAISER PERMANENTEQ A x y Fue Request (N4g) _ A
i ‘ Please type or prim clearly in blue or black ink.
FILE REQUESTED FOR
Employee Name (Last Name, First Name, initial) Employee ldentitication Number
A I-?0$cI , _.fY\6lY“l&ID ll-$@5]
Employees Former Name (tf applicable) Termination Date (if applicable) i
Faelllty Name fi
.»•·* ‘ L
Odlélcivid rvileivl 6I
FILE REQUESTED BY _ ly
' lj HR Consultant I] Manager [I Workers' Comp I] External I] Legal l
I] Employee [I Recruitment E Other investigation Specialist - E
Requestofs Name Last First initial Requestor'e Employee ldenlilication Number
Lei Charlotte r 000160451 yj
Work Phone Numberl Tieline Fax Number I Z?
( 510 ) 987-3202 _ ' ( 510 ) 873-5039
t=n.ei DOCUMENTS Reouesreo
. ~ _ g—0 2···· 0 6
Date file I documents needed by. {
Reason for request: EEO Investigation

Contents Requested: ` j_·
I] Personnel File (Note: Wol1 IE Personnel File (Entire mam personnel tile) tk
E Specific documents from the personnel tile you wish to review:
PPS 106 PPS 124 L
DELIVERY OF FILE I DOCUMENTS
I] Please send by inter-oftioe mail Tm Address 0 _
_ 1950 Franklin Street, 15th Floor I ii;
[I Please send by U.S. Mall _ a
V4 Pl se d b Airbome Ex ress my Sum Zip Coda ‘
* BB *"°" V p Oakland CA 94512 ··_*
¤ Pl BESB FAX **·€¤¤·=¤m¤~* I I=·=
Employee: To review your entire personnel file, you must meet with the HR Consultant in your Service Area. Your file will be {`Q
mailed to the HR Consultant in your Service Area 1-3 business days from the time the request is received, Please eqmap: me HR A
Consultant to arran ag intrnent to view your entire tile. V ..
E4! TT
» Requestofs nature Date `
K00422 `I
t Please keel; theiazueeeiptjoegg. or
Fax signed form to HR Service Center: 888-499-1502 (tieline 8-499-1502) Page 1 I1 _Q
or mall to: PO Box 12916, Oakland. CA 94604-2916 ·_ Phone: 877-4KP- HRSC (877-457-4772) 02.02.05 ` Qj

· Case 3:07-cv-03114-SI Document 48-18 Filed O9/O5/2008 FEq,e..3Qf4é
· m pl oym e nt
., . Development _
D e p a r t m e nt .
EMPLOYMENT oEvEr.ol> T DEPARTMENT iff 1210 ,;
,,:,,_ ,,0,, ,9,,3, W V Ibex _
SAN BERNARDINO CA 423·9037 IQ Ugilgu A I
.;...... MAYIOZDGE.
THIS NOTICE WAS MAlL% THE EMPLOYER/ADDRESS LISTED BELOW ON; 05/08/06
Q}., New Claim: X
KAISER PERMANENTE )> AUUIIIODBI Claim:
----—- 280 IIEST HACARTHUR BLVD K`: I Id C H ( ) li
ns` e ai. 800 300-5616 "
OAKLAND CA gkéoi Q Outside Calif. (800) 250-3913 5.
IMPORTANT: NOTICE OF UNEMPLOYMENT INSURANCE CLAIM FILED
_ This is anotice-tha-t_aclaim for unemploymem benefits has been-fdediFFo_rward it immediately to persons within your
organization who are responsible for handling claims. The time limit tor regyigg Is I0 gys from the mail date shown above. QQ
Failure to res mgy result in an increased Emggyment Tax Rate. `
The claimant provided us with the following infomation and listed you as his/her last employer; EI?
Claimants Name Social Security Number Effective Date of Claim; 0Ir/ 30/06 ii
I FERNANDO M DAROSA 572•'l9·5*l86 Last Date Worked; 01/01/06
Reason for Separation:
MY DOCTOR HAD HE OUT ON DISABILITY .
I. EXPLANATION AND INSTRUCTIONS FOR EMPLOYERS Y
You have received this form because the individual shown above has filed a claim for unemployment insurance benefits and has listed A
you as his/her most recent employer priorto filing this claim. No reply fs required It the claimant was laid ott due to lack of work and ‘_·‘
no other eligibility Issue has been identified. For detailed information on employer responsibilities in the unemployment insurance I
program, our DE 44, Califomia Employers Guide, is available upon request. _ fi
II, REPORTING FACTS - Respond in writing by completing Sections A, B, C on the reverse of this form. `
The law requires an employer to submit any facts fn hldher possession which may affect a cIaimant‘s eligibility for benefits. _
Furnlsh information if this claimant: ia
• voluntarily quit · Is not legally emitted to work in the U.S.
· Was discharged or fired for rexons other than lack of work. • Perfonned services as a sports or athletic participant and has
· Left work because of a trade dispute. reasonable assurance of performing such services in the next season.
a ls receiving a pension based on his/her prior wont. · Madefalse statements or withheld material information in filing for Q
• ls working on a full-time basis, or has eamings payable b¤¤¤I¤S· if
over $25.99, covering any time on or afterthe effective date • II Y0U am 6 5¤h¤¤I ¤mPI¤y¤f. also fumish information if the claimant Ly
of this claim as shown on the reverse side of _this fomt. _ I __ DHS? ¤_Q¤IiT¤¤I_I¤I'_0[fGg_S0¤¤Q¤ isj_u__rari:e of retumingjg__wprk_ I
· r~· ~· ····‘··‘*"rltTmr‘a¤Ié`rc‘i74ork,75vailable for, or seeklng"w¤rltZ II¤P¤¤¤¤I¤ MBKG ‘/¤¤I *€$¤¤¤$¤ 65 ¤¤¤'¤Pl¤'l¤ SS P¤$$IbI9§ YIIGSG facts ii
. Has rgfuggd Qmpiqymgm; 1 will be used in determining the claimants eligibility, 2;
A Department represemative may contact you for further eligibility information. lf a representative is unable to reach you, helshe may leave
I I a message for you to retum the telephone call. lf after 48 hours no response has been received, the Department is required to make an
eligibility decision based on available information. .
III. TIME LIMITS FOR REPLYING I
Submit facts in writing to the field office shown at the top ot this form withln 10 days of the mail date shown above. If your
mailing is late, explain your reasons for delay as the time limit may be extended only for good cause. You may reply on this fomi in the `_
space provided in Section IV, on additional sheets as needed, or by separate letter. Always include your State Employer Account
Number and include the claimants Social Security Number as it appears on the claim and in your payroll records, AZ,
If you submit facts in a timely manner, a detemtination will be issued conceming the claimants eligibility. In addition, if facts are sub-
mitted regarding a quit or discharge, a ruling will be issued advising an employer with a reserve account as to whether his/her account {Q
will be subiect to changes resulting from benefits paid. To obtain a ruling on any pnor quit or discharge involving this claimant, you must -9
furnish facts within IO days of the mail date shown above.
ADDITIONAL INFORMATION ON EMPLOYER RESPONSIBILITIES IS SHOWN ON TI-IE REVERSE {
Mail your response tothe EDD office shown in the above upper left-hand comer,
M . .. .. . ___ I
DE tt0tCIZ/ Rev. 4 (tos) EMPLOYER NOTICE .
, K00423 cu-nziv I

Case 3:07-cv-O'3114—SI Document 48-18 Filed O9/O5/2008 Page 4 of 4 I
’ lv. REPORTING ELIGIBILITY INFORMATION: Do not return this lorm unless Sections A or B are completed. It is necessary if
to complete Section C f _ all responses. V
· ‘ A. REPORTING FACTS: I ° I
Claimant Social Security Number _. __ __ - .. _.. ___ .._ Date Last Worked was: __ _ - __ _ - _ _
Qmm your payroll records) (Mbflth Day Year) Q;
e. 011-ren courensmon; 0
Complete the following if you paid or will pay any compensagrt ide from regular salary, covering any time on or after the effective date of
this claim. No emry is required if the claimant has been separa your employ for any indefinite period and has or will receive only [Q
vacation pay. . % Z5
Amount S Type of_ Payment _€ for period lmm __ ____ through -. ;. . _..-
C. EMPLOYER CERTIFICATION: THE ABOVE STATEMENTS WERE TAKENQOM BUSINESS RECORDS OR ARE BASED ON KNOWLEDGE
OF THE UNDERSIGNED. ` L
PRINT name ot person to contact for further information: »
Name of contact: Telephone N0. (_ ___ ,_ ) ___ __, __ - ____ Ext. _____
Employer; DGIBZ
, » STATE EMPLOYER {3
_ Accounrr M0.: ... _ - - _... Signed By:
V. ELIGIBILITY DETERMINATION ‘ _
I - Il may be necessary to contact you by telephone or letter for eligibility information if an issue is identified by the field office. Regardless of
whether such contact is made however, unless you respond lo the notice by mall as described In this notice, you will not be emitted to a `
written notice ol the D•parlment's decision. ji
rrreonnrrr; - · Q.
I • Section 1327 of the UI Code provides for an extension of the 10-day response period if, after the 10-day period, you acquire knowledge
l of facts that may affect the eligibility ofthe claimant and facts could not reasonably have been known within the period. However, you _ .;.
` must provide the Department with these facts within 10 days of acquiring them. j
· • Section 1142(a) provides that an employer wtto willfully makes a false statement or representation, or willfully fails to report a material
fact in connection with a separation issue may be assessed a penalty of up to 10 times the claimants weekly benefit amount.
Section 1t42(b) provides that an employer who willfully makes a false statemem or representation or willfully fails to report a material if
ram in submitting a written statement concemingteasonable assurance of a claimant's reemployment, as defined in Section 1253.s(g), _j
may be assessed a penalty of up to 10 times the claimants weekly benefit amount. _
' · Section 2101 of the Ul Code provides that it is a misdemeanor to willfully make a false statement or knowingly fall to disclose a material
. tact to obtain increase, reduce, or defeat any payment of benefits. ;;;
rt
PLEASE MAIL YOUR RESPONSE TO THE EDD OFFICE AND ADDRESS SHOWN IN THE UPPER LEFT -HAND CORNER ON
THE REVERSE SIDE OF THIS FORM. I
'I'l'Y (non-voice) (800) 815-9387 `
——i__ f " R . L . . . W. . . - TiT‘TT“""‘ "‘“*?"“”? ~r+·i‘·*··<···t%·i::·1*··ri··r<·~· :itr· _iT"."‘"‘ ‘ir*i " " i it ‘i ‘_‘
K00424 _

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