DI / DE 817F

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

Declaration of Forged Endorsement of Paid Family Leave (PFL) Check

 
Date:
Blank Line
For Office Use Only:
Blank Line
CED:
Blank Line
Blank Box  
 
To report a forged endorsement of a Paid Family Leave (PFL) benefit check:
  1. Complete, sign, and date all copies of the enclosed Declaration of Forged Endorsement of Paid Family Leave (PFL) Check, DE 817F. Note: Departmental policy requires a separate DE 817F packet for each check reported missing, lost, or stolen. Listing multiple checks will delay processing.
  2. Complete, sign, and date PART I of the enclosed Claimant Missing Check Incident Report, DE 8784.
  3. Return the original, duplicate, and triplicate of the DE 817F and the DE 8784 to us in the enclosed envelope.

You may keep this transmittal and the claimant copy of the DE 817F for your records.

If you have any questions about completion of this Declaration, please call our customer service center at 1-877-238-4373. Hearing and speech-impaired persons only may contact us via teletypewriter (TTY (non-voice)) at 1-800-445-1312.

Blank Line Paid Family Leave (PFL) Program Representative 

Enclosures:
DE 817F
 
DE 8784
 
Courtesy Reply Envelope

Instructions - You May Keep This Page For Your Records

DE 817F Rev. 2 (11-21) (INTRANET)

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

Declaration of Forged Endorsement of Paid Family Leave (PFL) Check

 
For Office Use Only:
Blank Line
CED:
MM/DD/YY
Office Number:
225
I,
Blank line 
,
residing at
Blank line 
,
Blank Line
,
declare that the endorsement of the Paid Family Leave (PFL) check listed below, purporting to be endorsed by
Blank Line
, and paid by the State Treasurer, was not authorized or written by me and that the endorsement of the check is a forgery;

Check Number

Issue Date

Number Benefit Days

Through Date

Amount
Blank line
MM/DD/YY
Blank line
MM/DD/YY
$0.00

I further declare that I have no knowledge of the endorsement of the above-listed check and that no part of the amount of the check listed above has been received by me, directly or indirectly, or applied to any use or purpose in my behalf.

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

Signed on
Blank lineMonth
Blank lineDay
Blank lineYear
at
Blank lineCity
Blank lineState
Blank line
PAYEE'S SIGNATURE
Blank line
PAID FAMILY LEAVE (PFL) PROGRAM REPRESENTATIVE

Return original, duplicate and triplicate. Keep the transmittal/instructions and the claimant copy for your records.

DO NOT WRITE IN SPACE BELOW

Paid by State Treasurer on Blank

Contents examined and reissuance recommended by Insurance Accounting Division

By:
Blank line 
Date:
Blank line 

Reissuance approved by Investigation Division

By:
Blank line 
Date:
Blank line 

Original

DE 817F Rev. 2 (11-21) (INTRANET)

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

Declaration of Forged Endorsement of Paid Family Leave (PFL) Check

 
For Office Use Only:
Blank Line
CED:
MM/DD/YY
Office Number:
225
I,
Blank line 
,
residing at
Blank line 
,
Blank Line
,
declare that the endorsement of the Paid Family Leave (PFL) check listed below, purporting to be endorsed by
Blank Line
, and paid by the State Treasurer, was not authorized or written by me and that the endorsement of the check is a forgery;

Check Number

Issue Date

Number Benefit Days

Through Date

Amount
Blank line
MM/DD/YY
Blank line
MM/DD/YY
$0.00

I further declare that I have no knowledge of the endorsement of the above-listed check and that no part of the amount of the check listed above has been received by me, directly or indirectly, or applied to any use or purpose in my behalf.

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

Signed on
Blank lineMonth
Blank lineDay
Blank lineYear
at
Blank lineCity
Blank lineState
Blank line
PAYEE'S SIGNATURE
Blank line
PAID FAMILY LEAVE (PFL) PROGRAM REPRESENTATIVE

Return original, duplicate and triplicate. Keep the transmittal/instructions and the claimant copy for your records.

DO NOT WRITE IN SPACE BELOW

Paid by State Treasurer on Blank Line

Contents examined and reissuance recommended by Insurance Accounting Division

By:
Blank line 
Date:
Blank line 

Reissuance approved by Investigation Division

By:
Blank line 
Date:
Blank line 

Duplicate

DE 817F Rev. 2 (11-21) (INTRANET)

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

Declaration of Forged Endorsement of Paid Family Leave (PFL) Check

 
For Office Use Only:
Blank Line
CED:
MM/DD/YY
Office Number:
225
I,
Blank line 
,
residing at
Blank line 
,
Blank Line
,
declare that the endorsement of the Paid Family Leave (PFL) check listed below, purporting to be endorsed by
Blank Line
, and paid by the State Treasurer, was not authorized or written by me and that the endorsement of the check is a forgery;

Check Number

Issue Date

Number Benefit Days

Through Date

Amount
Blank line
MM/DD/YY
Blank line
MM/DD/YY
$0.00

I further declare that I have no knowledge of the endorsement of the above-listed check and that no part of the amount of the check listed above has been received by me, directly or indirectly, or applied to any use or purpose in my behalf.

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

Signed on
Blank lineMonth
Blank lineDay
Blank lineYear
at
Blank lineCity
Blank lineState
Blank line
PAYEE'S SIGNATURE
Blank line
PAID FAMILY LEAVE (PFL) PROGRAM REPRESENTATIVE

Return original, duplicate and triplicate. Keep the transmittal/instructions and the claimant copy for your records.

DO NOT WRITE IN SPACE BELOW

Paid by State Treasurer on Blank Line

Contents examined and reissuance recommended by Insurance Accounting Division

By:
Blank line 
Date:
Blank line 

Reissuance approved by Investigation Division

By:
Blank line 
Date:
Blank line 

Triplicate

DE 817F Rev. 2 (11-21) (INTRANET)

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

Declaration of Forged Endorsement of Paid Family Leave (PFL) Check

 
For Office Use Only:
Blank Line
CED:
MM/DD/YY
Office Number:
225
I,
Blank line 
,
residing at
Blank line 
,
Blank Line
,
declare that the endorsement of the Paid Family Leave (PFL) check listed below, purporting to be endorsed by
Blank Line
, and paid by the State Treasurer, was not authorized or written by me and that the endorsement of the check is a forgery;

Check Number

Issue Date

Number Benefit Days

Through Date

Amount
Blank line
MM/DD/YY
Blank line
MM/DD/YY
$0.00

I further declare that I have no knowledge of the endorsement of the above-listed check and that no part of the amount of the check listed above has been received by me, directly or indirectly, or applied to any use or purpose in my behalf.

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

Signed on
Blank lineMonth
Blank lineDay
Blank lineYear
at
Blank lineCity
Blank lineState
Blank line
PAYEE'S SIGNATURE
Blank line
PAID FAMILY LEAVE (PFL) PROGRAM REPRESENTATIVE

Return original, duplicate and triplicate. Keep the transmittal/instructions and the claimant copy for your records.

DO NOT WRITE IN SPACE BELOW

Paid by State Treasurer on Blank Line

Contents examined and reissuance recommended by Insurance Accounting Division

By:
Blank line 
Date:
Blank line 

Reissuance approved by Investigation Division

By:
Blank line 
Date:
Blank line 

Claimant Copy

DE 817F Rev. 2 (11-21) (INTRANET)

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

Claimant Missing Check Incident Report

Check Number
 
Week Ending
(UI) (DI) 
Blank Line
 
Blank Line
(UI) (DI) 
Blank Line
 
Blank Line
(UI) (DI) 
Blank Line
 
Blank Line
(UI) (DI) 
Blank Line
 
Blank Line
PART I - to be completed by Claimant at the time he/she executes the Declaration of Forged Check Endorsement (DE 817D / DE 817DIS / DE 817F). PLEASE PRINT CLEARLY.
1. Name Blank space 2. For Office Use OnlyBlank space
3. Driver License/Identification Card Number Blank space 4. Full Date of Birth Blank space
5. Current Address Blank space 6. Phone Number Blank line 
7. Names of Other People Using This Same Address Blank space 8. Is Address Above Same as Address of Checks?
9. If address above is different than address of check, did you file a change of address with the Post Office?
If yes, approximate date:
Blank line  
10. Please check the box next to the true answer below and sign your name at the end of each line.
Did you receive this check? Blank line 
Did you lose this check after receiving it? Blank line 
Did you endorse this check after receiving it? Blank line 
Did you authorize anyone to sign or cash this check? Blank line 
11. Complete for Lost or Stolen Checks:
If check was stolen, did you report it?
If yes, to whom?
Blank line  
 
Blank line  
 
Date Reported:
Blank line  
Additional comments (circumstances pertaining to the missing check)
Blank line 
Blank line 
Blank line 
Blank line 
Claimant Signature Blank space Date Blank space
PART II - to be completed by Departmental Representative after claimant has examined front and back of copy of missing check(s) and has executed Declaration(s) of Forged Check Endorsement (DE 817D / DE 817DIS / DE 817F)
1. Can claimant identify individual who signed his/her name as first endorsement?
If yes, answer below:
Name Blank line  Relationship Blank line 
Address Blank line  Phone Number Blank line 
2. Can claimant identify individual or entity who cashed this check (second endorser)?
If yes, answer below:
Name/Business Blank line  Relationship Blank line 
Address Blank line  Phone Number Blank line 
EDD RepresentativeBlank space Telephone Number Blank space Office Number
225
 DateBlank space
DE 8784 Rev. 9 (11-21) (INTRANET)