DI / DE 2513

SAMPLE, this page for reference only

RETURN TO:

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EDD Employment Development Department State of California Logo

800-480-3287

EDD Customer Account Number (EDDCAN) CLAIM ID SSN/ECN CED
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REQUEST FOR DELIVERY INFORMATION

TO AVOID UNDERPAYMENT/OVERPAYMENT of BENEFITS, complete and return this form to the address listed above as soon as possible after the birth of your child PLEASE PRINT WITH BLACK INK.

If you have already established an SDI Online account, you can submit this form online at www.edd.ca.gov You do not need to mail this form in if you submit it online.

1. What date was your child delivered?
MM/DD/YYYY
2. How was your child delivered (Check One):
3. Signature
I declare under penalty of perjury that the foregoing responses are, to the best of my knowledge and belief, true, correct, and complete. 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 and that such violation is punishable by imprisonment or fine or both.
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Your signature (Do Not Print)
Date signed
MM/DD/YYYY

DE 2513 Rev. 3 (6-16) (INTRANET)