You may contact Paid Family Leave (PFL) by calling ‎1-877-238-4373.

A list of Paid Family Leave (PFL) local office locations can be found by visiting edd.ca.gov/disability/Contact_DI.htm.

The address and phone number of Paid Family Leave will also appear on the Notice of Computation (DE 429D) issued at the time your benefit determination is made.

• Failure to supply any or all information may cause delay in issuing benefit payments 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, the EDD will disqualify you from receiving benefits or services and may initiate criminal prosecution against you.

• 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 family member receiving care, bonding, or military assist willappear 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 State Disability Insurance (SDI).
  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.
  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 their representatives.
• Information shall be disclosed to authorized agencies in accordance with California Unemployment Insurance Code (CUIC), sections 1095 and 2714.

A8.

Declaration and Signature. By my signature on this application statement, I (1) claim Paid Family Leave (PFL) Benefits and certify that throughout the period covered by this application I was providing care for, bonding with, or participating in a qualifying event with the recipient named above (2) authorize EDD to release my personal information as shown on this application to the care recipient's treating physician as they are respectively listed in Part C and Part D of this application (3) authorize my employer(s) to disclose EDD all facts concerning my employment that are within their knowledge and (4) 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 application statement are granted for a period of 15 years from the date of my signature or the effective date of the application, whichever is later.

*If your signature is made by mark (X), it must be attested by two witnesses with their addresses

Declaration and Signature. By my signature on this bonding certification, I authorize the medical provider, adoption agency, adoption party(ies), or foster care placement agency to disclose to the Employment Development Department all facts concerning the birth, adoption, or foster care placement of the above-named child. 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 or documents, 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 15 years from the date of my signature or the effective date of the claim, whichever is later.

Confirmation of medical disclosure authorization. I authorize my Physician/practitioner to disclose my current personal health information to my care provider and to the California Employment Development Department (EDD). I further understand that copies of my signature below are as valid as the original.

Authorized Representative signing on behalf of family member receiving care must complete the following I , ______________________________________ Blank Line, represent the family member receiving care or bonding in this matter as authorized by parental rightpower of attorney (attach copy)court order (attach copy) (for spouse or domestic partner, contact EDD).

Physician/Practitioner's certification and signature: I certify under penalty of perjury that this patient has a serious health condition and requires a care provider. I have performed a physical examination and/or treated the patient. I am authorized to certify a patient disability or serious health condition pursuant to California Unemployment Insurance Code (CUIC) section 2708.

Note: A complete and sufficient certification to support a request for PFL leave due to a qualifying event includes any available written documentation that supports the need for leave. Documentation may include; a copy of a meeting announcement for informational briefings sponsored by the military, a document confirming the military member’s Rest and Recuperation leave, an appointment with a third party (i.e., a counselor, school official, or staff at a care facility), or a copy of a bill for services for the handling of legal or financial affairs. If leave is requested to meet with a third party, the employee must provide the supporting documentation of the meeting that includes the name, address, and appropriate contact information of the individual or entity with whom you are meeting (i.e., either phone number, fax number, or email address of the individual or entity).

Declaration and Signature. By my signature on this military assist certification, 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 or documents, 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 15 years from the date of my signature or the effective date of the claim, whichever is later.

If leave is requested to meet with a third party, the employee must provide supporting documentation of the meeting that includes the name, address, and appropriate contact information of the individual or entity with whom you are meeting (i.e., either the phone number, fax number or email address of the individual or entity). The reason for a meeting can include: arranging for child or parental care, counseling, making financial or legal arrangements, acting as the military member’s representative before a federal, state or local agency for purposes of obtaining, arranging or appealing military service benefits, or attending any event sponsored by the military or military service organizations.

Please submit supporting documentation, if applicable.
Attach an additional sheet if more space is required.