First Name *

Last Name *

Address *

City *

Zip Code *

Phone Number

Ext.

Phone Number Type

Date of Birth *

What did you apply for? *

Date Applied for Claims *

What is your issue? *

If you selected other, please specify here.

In a few sentences please describe your issue? *

Have you certified for ALL weeks pending of benefits?

If no, which weeks have you certified for?

How many weeks of benefits are you owed?

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

Have you contacted another elected official? *

REQUEST FOR ASSISTANCE AND AUTHORIZATION FOR RELEASE OF INFORMATION

Please carefully read the following:

By completing this form, I am requesting the Office of Assemblywoman Elhawary (the “Assemblywoman”) 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 Assemblywoman 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.

Disclaimer: Please do not send any personal identifiable information through this form that is not specifically requested. If we need additional information, such as your EDD number, we will contact you to request that information.

I agree that I will not submit any personal identifiable information through this form that is not specifically requested. If the Assemblywoman's office needs additional information, such as my EDD number, the office will contact me to request that information. *

Your privacy is very important to us. By clicking submit, you are agreeing to the practices described in the Privacy and Conditions of Use.