DI / DE 2504RE

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

REQUEST TO RE-ESTABLISH A BONDING CLAIM FOR PAID FAMILY LEAVE (PFL)

Complete this form if you are taking additional time off work to continue bonding with the same child named on your original Paid Family Leave (PFL) bonding claim.

You may submit your claim online through: How to file a PFL Claim (edd.ca.gov/en/Disability/How_to_File_a_PFL_Claim_in_SDI_Online.htm) or you may choose to mail in the form to the PFL address listed below. If you choose to submit your form online DO NOT mail this form to the PFL office.

Blank box

Note: Complete and return this form to the PFL Office no later than 41 days from the date you are requesting to re-establish a bonding claim or you may lose benefits.

Complete all the requested information below by typing or printing and sign where indicated.

For Office Use Only:
Blank Line
Original claim start date:
Blank Line

Return to:

Paid Family Leave
PO Box 997017
Sacramento CA 95899-7017
1-877-238-4373
  1. I certify that I am taking time off work to bond with: (Child's Name)
    BlankLine
  2. My child's date of birth is BlankLine
  3. I requested my bonding benefits to begin on (date) BlankLine and end on (date) BlankLine
  4. My last day worked was (date) BlankLine I expect to or did return to work on (date) BlankLine
  5. Will you work part-time during the period you are claiming PFL benefits?
  6. Will you receive wages from your employer(s) during the period you are claiming PFL benefits?
    1. If yes, indicate type of pay:
  7. Have you claimed or do you plan to claim workers' compensation benefits for any period covered by your PFL claim?
  8. Do you have more than one employer?
  9. At any time during your receipt of PFL benefits, will you be (or were you) in the custody of law enforcement authorities because you were convicted of violating a law or ordinance?
Your Most Recent Employer (Name):Blank line
Employer's Address:Blank line
City:Blank line
State:Blank line ZIP Code:Blank line Phone:Blank line
By my signature on this claim statement, I (1) claim Paid Family Leave (PFL) benefits and certify that throughout the period covered by this claim I was/will be bonding with the care recipient named above (2) authorize my employer(s) to disclose to State Disability Insurance (SDI) all facts concerning my employment that are within their knowledge; and (3) authorize release and use of information as stated in the "Information Collection and Access" portion of my initial claim form. I understand that willfully making a false statement or concealing a material fact in order to obtain payment of benefits is a violation of California law punishable by imprisonment or fine or both. I declare under penalty of injury that the foregoing statement, including any accompanying statements or documents, is to the best of my knowledge and belief true, correct, and complete. I agree that photocopies of this authorization shall be as valid as the original and I understand that authorizations contained in this claim statement are granted for a period of fifteen years from the date of my signature or the effective date of this claim, whichever is later.
Signature
Blank Line
(Bonding Claimant)
Date
Blank Line

DE 2504RE Rev. 5 (11-21) (INTRANET)