Paid Family Leave Claim Notice Instructions

In order to claim Paid Family Leave (PFL) benefits which may be due, the enclosed form(s) must be completed. Please return no later than 20 days from the date of mailing or serving of this notice. For questions about completion of the enclosed form(s), please call ‎1-877-238-4373

Declaration of Individual Claiming Paid Family Leave (PFL) Benefits on Behalf of Deceased Claimant (DE 648F) Declaration of Individual Claiming Benefits Due an Incapacitated or Deceased Claimant (DE 2522) Declaration of Individual Acting as Authorized Representative for Incapacitated or Deceased Care Recipient (DE 1850)

For the following form(s), sign the name of the incapacitated/ deceased claimant or care recipient and then sign your name next to the claimant or care recipient’s name as, “By” Your Name.
Example:
John Doe By Jane Doe

Continued Claim Certification for Paid Family Leave (PFL) Benefits (DE 2580GF) or Other enclosure(s) Blank Line_____________________

Blank Box

EDD – Paid Family Leave

PO Box 997017

Sacramento, CA 95799-7017

DE 5128F Rev. 2 (6-21) (INTRANET)

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DI / DE 5128F

Paid Family Leave Claim Notice Instructions