DI / DE 4366PFL

SAMPLE, this page for reference only

EDD
PO Box 989010
West Sacramento, CA 95798-9010
Return To:  
EDD
PO Box 989010
West Sacramento, CA 95798-9010
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Claim Effective Date:
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Issue Date:
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For Office Use Only:
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Request for Eligibility Information for Paid Family Leave

We need to determine your eligibility for Paid Family Leave (PFL) benefits. Complete and mail this form, with the documents outlined on page two, to the address above by 
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If your information is not verified, you may be denied PFL benefits and be required to pay back the benefits you already received, including penalties. If your documents are mailed after the due date, include an explanation for the delay.
All information will be kept confidential. Citizenship and immigration status do not affect eligibility.
Provide the following information:
  1. What is your current residential address?
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    City:
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    ZIP Code:
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  2. How long have you lived at this address?
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    Years
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    Months
  3. Provide up to five other addresses you have used in the past three years. Start with your most recent address
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    City:
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    ZIP Code:
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DE 4366PFL Rev 1 (7-24) (INTRANET)

SAMPLE, this page for reference only

  1. Provide one copy of each document described below:
    • Proof of address showing your full name and residential address.
    • Valid photo identification showing your full name and date of birth.
    • Proof of wages from the past two years before your claim began.

I acknowledge the law provides penalties for any false statements or withheld information to receive benefits. I declare that the information provided is true and correct.

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Print Your Name
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Signature
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Date
Paid Family Leave Phone Numbers
English:
1-877-238-4373
Spanish:
1-877-379-3819
Cantonese:
1-866-692-5595
Vietnamese:
1-866-692-5596
Armenian:
1-866-627-1567
Punjabi:
1-866-627-1568
Tagalog:
1-866-627-1569
TTY (Non-voice):
1-800-445-1312
Online:
edd.ca.gov/PaidFamilyLeave
Proof of Address Examples
Provide any of the following as proof of address:
  • Utility bill (electricity, gas, garbage, or sewer), cable TV, phone, or property tax bill.
  • Rental agreement, proof of insurance, bank, or mortgage statement.
  • Registration verification as a renter or authorized user of a PO Box or private mailbox.
  • Government-issued federal, state, county, or city documents that include a mailing address.
Photo Identification Examples
Provide any valid identification from this list. For cards, include the front and back:
  • Identification card (state or municipal)
  • Driver's license (state, including REAL ID and AB 60 Driver's license, or foreign cards)
  • Passport (US or foreign)
  • Permanent Resident Card (Green Card)
  • Certificate of Naturalization
  • US nonimmigrant visa
  • Border Crossing Card (DSP-150)
  • Citizenship card (US or foreign)
  • Consular ID card
  • Employment Authorization Document
Proof of Wages Documentation
Provide one or more of the following as proof of wages:
  • W-2 forms from the last two calendar years.
  • Pay stubs or payment statements that display:
    • Dates within the last two years prior to your claim.
    • Your first name (or first initial) and last name.
    • At least the last four digits of your Social Security number (SSN) or your employee identification number.
Additional Documentation Requirements
  • If you have previously worked under a different name or SSN, provide:
    • An explanation for using different names or SSN.
    • Relevant documentation, such as pay stubs, W-2 forms, or other wage statements (Note: SSA statements are not sufficient).
Note on Eligibility:
  • Citizenship and immigration status do not affect eligibility for PFL benefits. You must provide documentation for all names and SSNs under which you have worked.

If you received this notice but did not apply for PFL benefits, you should immediately report suspected fraudulent activity by visiting askedd.edd.ca.gov and selecting Report Fraud If you do not have access to the internet, you may contact the Fraud Hotline at ‎1-800-229-6297.

DE 4366PFL Rev 1 (7-24) (INTRANET)