Employment Development Department (EDD) Assistance Form

Claim Holder Contact Information

First Name *

Last Name *

Address *

City *

Zip Code *

Phone Number

Ext.

Phone Number Type

Have you already contacted another elected official for assistance with this issue? *

Yes

If Yes, please list any other elected officials you have contacted.

Claim Information

Please answer the following questions as accurately as possible.

Provide one of the following:
- EDD Customer Account Number (10 digits)
- Disability or PFL Claim Number (DI or PF followed by 10 digits)
- Social Security Number *

What date did you apply for this claim? *

What types of benefits did you apply for? *

Unemployment Insurance (UI)

State Disability Insurance (SDI)

Paid Family Leave (PFL)

IF "UNPAID BENEFITS" IS SELECTED, how many weeks of benefits are you owed?

IF "UNPAID BENEFITS" IS SELECTED, have you certified for ALL weeks that have pending benefits?

Yes

When was the last time you received a communication from EDD (via mail, phone, or text)? *

Authorization for Release of Information

Please carefully read the following:

By Completing this form, I am requesting the Office of Assemblymember Bryan (the "Assemblymember") to assist me in working with the Employment Development Department (EDD) on my claim. I acknowledge that this may require the release of information contained in my records the dissemination of which may be prohibited by law. Therefore, I hereby authorize EDD and the Assemblymember to share all relevant portions of my records with each other, and to discuss matters relating to those records and my claim, until my claim is resolved.

I agree that I will not submit any personal identifiable information through this form that is not specifically requested. if the Assemblymember's office needs additional information the office will contact me to request that information. *