DI / DE 2501FP

SAMPLE, this page for reference only

PAID FAMILY LEAVE
PO BOX 997017
SACRAMENTO CA 95899-7017

RETURN TO :

EDD-PAID FAMILY LEAVE
PO BOX 997017
SACRAMENTO CA 95899-7017
FIRSTNAME M LASTNAME
1234 SAMPLE STREET
ANY TOWN CA 99999-9999

Our records indicate you are a new mother receiving State Disability Insurance (SDI) Benefits for a pregnancy-related disability. After your baby is born and you have recovered from your disability, you may be eligible for Paid Family Leave (PFL) benefits if you remain off work to bond with your baby. NOTE: If you wish to claim additional PFL benefits for reasons other than bonding, please call ‎1-877-238-4373.

CLAIM FOR PAID FAMILY LEAVE (PFL) BENEFITS - NEW MOTHER

If you wish to claim PFL benefits, please complete the requested items below and return this form to the PFL office within 41 days from date you want your PFL claim to begin. If you had a multiple birth, provide information for one only.

FOR OFFICE USE ONLY
Blank line
SDI CLAIM EFFECTIVE DATE
MM/DD/YYYY
FINAL DATE OF SDI BENEFITS
MM/DD/YYYY
1.
Has your address or telephone number changed since you received this form?
(If "Yes", correct below.)
Blank line
2.
Have you completely recovered from your pregnancy-related disability as of the "FINAL DATE OF SDI BENEFITS" shown above?
3.
Do you want your PFL claim to begin on the day after the "FINAL DATE OF SDI BENEFITS" shown above
If "No", enter below the date you want your PFL claim to begin (MM/DD/YYYY) .
Blank line
If you need more information regarding when to begin your PFL claim, call ‎1-877-238-4373.
4.
Do you want to claim the full maximum benefit weeks now?
If you answered "No", enter the date you want to end your PFL bonding claim (MM/DD/YYYY)
Blank line
5.
Will your employer require you to take paid vacation before beginning family leave?
6.
Will your employer continue to pay you wages during your family leave?
7.
Do you have more than one employer?
8.
Your baby's name
FIRST
Blank line
MIDDLE INITIAL
Blank line
LAST
Blank line
9. Your baby's date of birth (MM/DD/YYYY)
Blank line
10. Your baby's gender
11.
Have you claimed - or do you plan to claim - workers' compensation benefits for any portion of the period covered by this PFL claim?
12.
Select your preferred payment method
For Office Use Only
Blank line

Declaration and Signature. By my signature on this claim statement, I (1) claim Paid Family Leave (PFL) Benefits and certify that throughout the period covered by this claim I was/will be bonding with my new infant;(2) authorize my employer(s) to disclose to State Disability Insurance all facts concerning my employment that are within their knowledge; and (3) authorize release and use of information as stated in the "Information Collection and Access" portion of this form. I understand that willfully making a false statement or concealing a material fact in order to obtain payment of benefits is a violation of California law punishable by imprisonment or fine or both. I declare under penalty of perjury that the foregoing statement, including any accompanying statements, is to the best of my knowledge and belief true, correct, and complete. I agree that photocopies of this authorization shall be as valid as the original and I understand that authorizations contained in this claim statement are granted for a period of fifteen years from the date of my signature or the effective date of the claim, whichever is later.

YOUR SIGNATURE
Blank Space
DATE SIGNED
MM/DD/YYYY
Blank line

USE BLACK INK TO COMPLETE THIS FORM

DE 2501FP Rev. 2 (6-20)

SAMPLE, this page for reference only

FEDERAL PRIVACY ACT. EDD requires disclosure of Social Security account numbers on a mandatory basis to comply with California Unemployment Insurance Code (CUIC), sections 1253 and 2627; with California Code of Regulations (CCR), title 22, sections 1085, 1088, and 1326; with Code of Federal Regulations, title 20, Part 604; and with U.S. Code, title 8, sections 1621, 1641, and 1642.

INFORMATION COLLECTION AND ACCESS. State law requires the following information to be provided when collecting information from individuals:

Agency Name:
Employment Development Department (EDD)		 Title of Official Responsible for Information Maintenance:
Manager, EDD Paid Family Leave (PFL) Office
Local Contact Person:
Manager, EDD Paid Family Leave (PFL) Office		 Address and Telephone Number:
The address and phone number of Paid Family Leave (PFL) will appear on the Notice of Computation (DE 429D) , issued at the time your benefit determination is made.
Maintenance of the information is authorized by:
California Unemployment Insurance Code (CUIC), sections 2601 through 3305.
California Code of Regulations (CCR), title 22, sections 2706-1, 2706-3, 2708-1, 2710-1
Consequences of not providing all or any part of the requested information:
Failure to supply any or all information may cause delay in issuing benefit checks or may cause you to be denied benefits to which you are entitled.
If you willfully make a false statement or representation or knowingly withhold a material fact to obtain or increase any benefit or payment, EDD will disqualify you from receiving benefits and/or services and may initiate criminal prosecution against you.
Principal purpose(s) for which the information is to be used:
To determine eligibility for Paid Family Leave (PFL) benefits.
To be summarized and published in statistical form for the use and information of government agencies and the public. (Neither your name and identification nor the name and identification of the care or bonding recipient will appear in publications.)
To be used to locate persons who are being sought for failure to provide child or spousal support.
To be used by other governmental agencies to determine eligibility for public social services under the provisions of California Welfare and Institutions Code, Division 9.
To be used by the EDD to carry out its responsibilities under the California Unemployment Insurance Code (CUIC).
To be exchanged pursuant to California Unemployment Insurance Code (CUIC), section 322, and California Civil Code, section 1798.24, with other governmental departments and agencies, both federal and state, which are concerned with any of the following:
  1. administration of an unemployment insurance program;
  2. collection of taxes which may be used to finance unemployment insurance (UI) or disability insurance (DI);
  3. relief of unemployed or destitute individuals;
  4. investigation of labor law violations or allegations of unlawful employment discrimination;
  5. the hearing of workers' compensation appeals;
  6. whenever necessary to permit a state agency to carry out its mandated responsibilities where the use to which the information will be put is compatible with the purpose for which it was gathered; or
  7. when mandated by state or federal law. Disclosures under California Unemployment Insurance Code (CUIC), section 322, will be made only in those instances in which it furthers the administration of the programs mandated by that Code.
Pursuant to California Unemployment Insurance Code (CUIC), sections 1095 and 2714, information may be revealed to the extent necessary for the administration of public social services or to the Director of Social Services or his/her representatives.
Information shall be disclosed to authorized agencies in accordance with California Unemployment Insurance Code (CUIC), sections 1095 and 2714.

DE 2501FP Rev. 2 (6-20)