(Issued Pursuant to Provisions of Section 1089 of the California Unemployment Insurance Code)

Employee Name: SSN:

Your employment status has changed for the reason checked below:

[Company Name] Date: ______________________

[Company Address]

[Company Phone] HR Director Signature:_______________________

[City, State ZIP]

Notice Acknowledgment

I received a copy of this notice on: Date:______________ Signature:_________________________

| Voluntary quit effective: Date:

| Discharge effective: Date: Reason:

| Layoff effective: Date:

| Demotion-decrease in work hours and/or wages effective: Date:

| Refusal to accept available work effective: Date: