or0875
ssN: 575'13-2719
ilArEs DANIEL K KAUIIE
DAIE rssuED. ostostoe pAcE 1
--_ PLEASE DISREGARII THE FORII Oil THE BACK OF THIS STUB - DO I{OT RETURI{
KEEP THIS STATEI.IENT
FOR YOUR RECORDS.
SSN: 5?5'13-2719
NAIIE: DANIEL K KAUWE
WEEKLY RATE: $471.OO
WEEKLY RATE IS FOR 7 DAYS
i,: r i:i:[ri!J!.:\/A ii:slr-: TALON PARA su Rf.CoRD PEnSONAL
EXCEPT FOR THE I,IANDATORY 7-DAY WAITING PERIOD, YOU },ILL BE PAID FOR EVERY DAY YOU ARE ELIGIBLE FOR
BENEFITS, INCLUDING WEEKENDS.
IF YOU ARE NOT PAID FOR ANY DAYS, YOU I.IILL BE NOTIFIED WHAT DAYS WERE NOT PAID AND WHY THEY }.IERE NOT PAII)
IN THE
'IESSAGE
AREA BELOW. THE OFFICE PROCESSING YOUR CLAIM IS:
EMPLOYMENT DEVELOPI.IENT DEPARTI4ENT
TELEPHONE 3 ( 800 ) +80-3287
' PO BOX 10402
VAN NUYS CA
9L+LO_O4O2
THE ATTACHEII CHECK IS FOR STATE DISABILITY
IIIISURANCE FOR THE FOLLOlfIlilG PERIOII(Sl2 OA/24/09 THROUGH 09/06/09.
NO. OF IIAYS
BEI{EFIT A,iIT.
A,'IT. I}EDUCTED
AIIT. PAIII
14
$942.00
$0.00
$942.00
IIESSAGE-AREA
IMPORTANT NOTICE:
IF you Do Nor UNDERSTAND
ANy FoRr,r sENT To you By rHIs oFFIcE, coNTAcr us FoR
ASSISTANCE
AT THE TELEPHoNE NUMBER SHOI/N ON THE CHECK STATEI,IENT.
DATE TSSUED
Og/Og/Og
CLAIlif EFFECTIVE DATE: 10/13/OB
-:
:=::=:==!
=:=!:==:
tJ-:::::==
F-=!==!
.'.,-:
u--
tu-:
-:U::
E::-:
:
::
rr'i ;-; ir:t(rttAi
Ctl PAD61 Rev. I (/ 07) FLASH
DATE ISSUED:
006821
o9t22to9
PAGE 1
WEEKLY RATE: $471.OO
WEEKLY RATE IS FOR 7 DAYS
EXCEPT FOR THE I,{ANDATORY 7-DAY }IAITING PERIOD. YOU WILL BE PAID FOR EVERY DAY YOU ARE ELIGIBLE FOR
BENEFITS, INCLUDING HEEKENDS.
IF YOU ARE NOT PAID FOR ANY DAYS, YOU I.IILL BE NOTIFIED WHAT DAYS HERE NOT PAID AND I.IHY THEY I.IERE NOT PAII)
IN THE l'lESSAGE AREA BELOW. THE OFFICE PROCESSING YOUR CLAIi'l IS:
El.'tPLOYl,lENT
DEVELOP|.'IENT
DEPARTMENT
TELEPHONE: ( 8OO ) 480-3287
P0 BOX 10402
VAN NUYS CA
9L4LO-O4O2
THE ATTACHED CHECK IS FOR STATE IIISABILITY
IIIISURANCE FOR THE FOLLOIIII{G PERIOD(St. 09/07/09
THROUGH 09/20/09.
1IO. OF DAYS
BET|EFIT AIIT.
AAT. TIEIIUCTED
AIIT. PAID
!4
$942.00
$0.00
$942. OO
:
IESSAGE-AR