SAMPLE, this page for reference only

Request for Information

Please complete and return this form to the Paid Family Leave (PFL) mailing address listed above. Be sure to include your claim for PFL benefits if one is attached.

Respond only to the item(s) marked with an "X" so that we can determine your eligibility for PFL benefits.

1. Correct and complete name and address of your employer and the last day worked for this employer.
   1. Blank Line

      Employer's Business Name

      Blank Line

      Employer's Phone Number
   2. Blank Line

      Employer's Business Address
   3. Blank Line

      City

      Blank Line

      State

      Blank Line

      Zip Code
   4. Blank Line

      Last Day Worked
2. Your occupation with this employer:

   Blank line
3. Your date of birth:

   Blank line
4. Please print your street address, state, and zip code information.
   1. Blank Line

      Street Name/Number
   2. Blank Line

      City

      Blank Line

      State

      Blank Line

      Zip Code
   3. Blank line

      Signature

       

      Blank line

      Date

       

DE 5006F Rev. 2 (11-21) (INTRANET)