DI / DE 2566F

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Mailing Date:

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For Office Use Only:

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Claim ID:

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Request for Additional Information

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We have received your claim for benefits. To complete the processing of your claim, we need additional information. Please mail the item(s) checked below within 10 calendar days in the enclosed, self-addressed envelope. Unless otherwise indicated, you do not have to send the originals.

Photocopy of identification showing your picture and your date of birth (for example, California driver license, California identification card, or resident alien registration card).

Proof of Social Security number (SSN) ownership. You must provide original verification of SSN from the Social Security Administration (SSA). Do not send an original or copy of your Social Security card. It will not satisfy this requirement. (You may contact the Social Security Administration (SSA) at ‎1-800-772-1213 or online at www.ssa.gov).

Proof of wages paid to you by the employers for whom you worked from Blank Line to Blank Line (for example, photocopy of paycheck stubs or W2 forms).

If you have worked under any other names in the past, for each name used please provide that name, an explanation for working under that name, and documentation proving you worked under that name (for example, photocopy of paycheck stubs or W2 forms).

If you have worked under any other Social Security numbers (SSN) in the past, for each number used please provide that SSN, an explanation for working under that SSN, and documentation proving you worked under that SSN (for example, photocopy of paycheck stubs or W2 forms).

Please respond within 10 calendar days from the date of this request. Your failure to respond may result in denial of your claim.

Department Representative

State Disability Insurance

‎PO Box #

City, State 99999-9999

DE 2566F (11-21) (INTRANET)

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Mailing Date:

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For Office Use Only:

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Claimant:

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Claim ID:

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Request for Employment Information

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This office has received a claim for State Disability Insurance (SDI) Paid Family Leave (PFL) Non-industrial Disability Insurance (NDI) benefits for the above-named individual who has listed you as his/her last employer. California Unemployment Insurance Code (CUIC), section 1092, requires that employers provide the information necessary for Employment Development Department (EDD) to administer this program.

To assist us in processing this claim, please respond to the questions below and return this form in the enclosed, self-addressed envelope within three working days:

Caption text
Question	Answer
DATE EMPLOYEE WAS HIRED Blank Space	EMPLOYEE'S DATE OF BIRTH Blank Space	OTHER SOCIAL SECURITY NUMBERS USED BY EMPLOYEE Blank Space
LAST DATE EMPLOYEE WORKED Blank Space	OTHER NAMES USED BY EMPLOYEE Blank Space
DATE EMPLOYEE RETURNED TO WORK Blank Space	EMPLOYEE'S LAST KNOWN HOME ADDRESS Blank Space
ATTACH A COPY OF THE EMPLOYEE'S ID, W4, AND I9
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SIGNATURE OF PERSON COMPLETING FORM Blank Space	DATE SIGNED Blank Space
PRINT NAME Blank Space	TITLE Blank Space	TELEPHONE NUMBER Blank Space

DATE EMPLOYEE WAS HIRED

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EMPLOYEE'S DATE OF BIRTH

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OTHER SOCIAL SECURITY NUMBERS USED BY EMPLOYEE

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LAST DATE EMPLOYEE WORKED

Blank Space

OTHER NAMES USED BY EMPLOYEE

Blank Space

DATE EMPLOYEE RETURNED TO WORK

Blank Space

EMPLOYEE'S LAST KNOWN HOME ADDRESS

Blank Space

ATTACH A COPY OF THE EMPLOYEE'S ID, W4, AND I9

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SIGNATURE OF PERSON COMPLETING FORM

Blank Space

DATE SIGNED

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PRINT NAME

Blank Space

TITLE

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TELEPHONE NUMBER

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Thank you for your assistance.

Department Representative

State Disability Insurance

‎PO Box #

City, State 99999-9999

DE 2576 Rev.5 (11-21) (INTRANET)

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DI / DE 2566F

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