(Check one box only and sign your name in the space provided)

1. I, Blank line, declare that I earned the following wages during one or more of the quarters shown during or preceding the base period used for my Disability Insurance (DI) or Paid Family Leave (PFL) claim as shown on the Notice of Computation, ‎DE 429D or ‎DE 429DF form.
2. I, Blank line, declare that I performed no services in employment for 60 days or more but was actively seeking work during one or more of the following quarters of the base period used for my Disability Insurance (DI) or Paid Family Leave (PFL) claim as shown on the Notice of Computation, ‎DE 429D or ‎DE 429DF form.

All communications regarding this claim must include your Social Security account number and be sent to the address shown below. If you have any questions or need assistance, please call‎ 1-800-480-3287.

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