DI / DE 5005F

SAMPLE, this page for reference only.

EDD Employment Development Department State of California Logo

Request for Additional Labor Market Information – Paid Family Leave (PFL)

 
Date of Mailing:
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For Office Use Only:
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To: 
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You recently filed a claim for PFL benefits that indicated the following:
  • The last date you worked was  Blank Line
  • The first date you need to provide family care or want to bond with a child is Blank Line
Before we can determine your eligibility for Paid Family Leave (PFL) benefits, we must know if you were either working, seeking work, or registered for work through the Employment Development Department (EDD). Please answer the questions below and return this form within 10 days of the mailing date shown above. If we do not hear from you, we will use the information we now have to determine your eligibility for PFL benefits.
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PFL Program Representative
‎1-877-238-4373
  1. If the dates shown in the box above are NOT CORRECT, please correct them.
  2. List your most recent efforts to find work.
    Employers Complete Address Telephone Numbers Date Contacted for Work
    (a)Blank space Blank space Blank space Blank space
    (b)Blank space Blank space Blank space Blank space
    (c)Blank space Blank space Blank space Blank space
  3. Union Name
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    Local Number
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    City
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  4. Date you registered with EDD to look for work
    Blank Line
  5. If you have not been looking for work, please explain why:
    Blank line  
    Blank line  

I certify under penalty of perjury that my responses are true and accurate.

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Your Signature
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Date
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Daytime Phone Number

DE 5005F Rev. 1 (11-21) (INTRANET)