EDD Assistance Request

First Name *

Last Name *

Address *

City *

Zip Code *

Phone Number

Ext.

Phone Number Type

Have you reached out to another elected official about this issue? *

Yes

Have you previously reached out to my office about this issue? *

Yes

What type of benefits did you apply for? *

When did you file your claim? *

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

Describe the problems you have been experiencing. *

REQUEST FOR ASSISTANCE AND AUTHORIZATION FOR RELEASE OF INFORMATION

Please carefully read the following:

By completing this form, I am requesting the Office of Assemblymember Kalra (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, such as my EDD number, the office will contact me to request that information.

By clicking here, I accept and agree to the terms in this form. *

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