DI / DE 2502FF

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

Religious Practitioner's Certification for Nonindustrial Disability Insurance - Family Care Leave (NDI-FCL) Benefits

(THIS FORM IS NOT APPLICABLE IF THE REASON FOR NDI-FCL IS TO BOND WITH A CHILD).

INSTRUCTIONS: To be completed by the certified religious practitioner. This certificate can be accepted only if you have been registered by the Employment Development Department (EDD). Submit this certification in lieu of Part E (Physician/Practitioner's Certification) of the Claim for Nonindustrial Disability Insurance - Family Care Leave (NDI-FCL) form (DE 8501F).

NDI-FCL Claimant (CARE PROVIDER)

  1. Claimant's Name:Blank line
  2. Claimant's Social Security Number:Blank line

Care Recipient Information (PERSON RECEIVING TREATMENT)

  1. Care Recipient's Name:Blank line
  2. Care Recipient's Date of Birth: MM/DD/YYYY
  3. Provide a detailed statement of the medical condition/symptoms displayed by the care recipient named above.
    Blank line
    Blank line
    Blank line
  4. Does the above named care recipient require care by the care provider (claimant)?
    1. 6a. If yes, the first date care is needed: MM/DD/YYYY
    2. 6b Date you estimate care recipient will no longer require care by the care provider: MM/DD/YYYY
  5. Approximately how many total hours per day will the care recipient require care by care provider? ________ Blank line
  6. I hereby certify that the care recipient is or was under my care, that the above statements in my opinion, truly describe the disability and the estimated duration thereof, and that the care recipient has professed to be an adherent of 
    (denomination)
    and that he/she depends entirely upon prayer or spiritual means for healing, and that I am a practitioner of
    (denomination)
    and have been registered in writing with the EDD as same.

Practitioner's Certification and Signature: I certify under penalty of perjury, this certification truly describes the patient's condition and need for care and the estimated duration thereof.

Blank Line
Print or Type Practitioner's Name
Blank Line
Practitioner's Siganture
Blank Line
Date Signed
Blank Line
Practitioner's Registration Number
Under sections 2116 and 2122 of the California Unemployment Insurance Code (CUIC), it is a violation for any individual who, with intent to defraud, falsely certifies the medical condition of any person in order to obtain disability insurance benefits, whether for the maker or for any other person, and is punishable by imprisonment and/or a fine not exceeding $20,000CUIC sections 1143 and 3305 require additional administrative penalties.

DE 2502FF (7-19) (INTRANET)