DI / DE 648F

SAMPLE, this page for reference only.

EDD Employment Development Department State of California Logo

For Office Use Only:
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Claimant's Name:
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CED:
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Declaration of Individual Claiming Paid Family Leave (PFL) Benefits on Behalf of Deceased Claimant

I,
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(Your name)
, declare:
  • that
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    (Name of deceased claimant)
    was certified to be deceased  on 
    Blank line
    (Date)
    in the city of
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    , state of
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    ;
  • that I am the
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    (Your relationship to the deceased-spouse, parent, etc.)
    of the above-named claimant ;
  • that I am legally entitled to receive on behalf of the above-named claimant any Paid Family Leave (PFL) benefits due, owing, and payable to him/her;
  • that I hereby request the PFL benefits due to the above-named claimant be paid and sent to me at the following address:
    Blank line(Your street address)
    Blank line
    (City)
    Blank line(State)
    Blank line(Zip or postal code)
    Blank line(Country, if not USA)
    Blank line
    (Area code and telephone number where you can be contacted)
    ;
  • that I understand any PFL benefit payments received by me may not be assigned to others and must be used in accordance with the law on behalf of the above-named claimant or his/her estate and for no other purpose;
  • that I will repay the Employment Development Department (EDD) for any misapplication of benefits received by me and for any loss, cost, damage, or liability which the EDD suffers by reason of delivering the benefit payment(s) to me;
  • that I understand the cashing of benefit payment(s) sent to me on behalf of the claimant or his/her estate constitutes a release of any and all claims the claimant may have against the EDD for said benefits;
  • that from MM/DD/YYYY through MM/DD/YYYY the above-named claimant required time off from work (part-time or full-time) to care for or bond with a previously designated care or bonding recipient;
  • and that I have shown on page two of this form all monies and wages received by the above-named claimant for MM/DD/YYYY through MM/DD/YYYY.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

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Signature of heir, executor, or administrator
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Date
DE 648F Rev. 4 (11-21) (INTRANET)
FOR DEPARTMENT USE ONLY Blank space 

SAMPLE, this page for reference only.

EDD Employment Development Department State of California Logo

For Office Use Only:
Blank line 
Claimant's Name:
Blank line 
CED:
Blank line 

Declaration of Individual Claiming Paid Family Leave (PFL) Benefits on Behalf of Deceased Claimant

Declaration of Money, Wages, or Workers' Compensation Received By or On Behalf of the Above-named Claimant for Blank Line__________ through Blank Line__________ You must report below payments of any type received from the claimant’s employer(s) for this period. (Examples: wages, vacation pay, sick leave pay, a loan, a gift, military reserve or National Guard pay, and any cash payment received under a Workers’ Compensation program.) DO NOT REPORT MONEY RECEIVED FROM STATE DISABILITY INSURANCE (SDI). If no money was received from any of the claimant’s employers or from a Workers’ Compensation program, enter "0" under GROSS AMOUNT RECEIVED.

Gross amount received
(If nothing was received, enter "0")		 Paid by (Name of employer or workers' compensation insurer)
$Blank space  Blank space 
$Blank space  Blank space 
$Blank space  Blank space 
$Blank space  Blank space 
$Blank space  Blank space 
$Blank space  Blank space 
$Blank space  Blank space 
Explanation or comments
Blank space 
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Signature of heir, executor, or administrator
Blank line
Date
DE 648F Rev. 4 (11-21) (INTRANET)