DI / DE 2580GF

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

For Office Use Only:
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CED:
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Mailing Date:
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Continued Claim Certification For Paid Family Leave (PFL) Benefits

 
Important: No check can be issued until you complete, sign, date, and return this form on
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(due date) If this date is past, please complete, sign, date, and return this form immediately.
You may lose benefits if this form is not mailed within 20 days starting on the due date OR 20 days after the day you received this form, if the due date is passed.
In order to pay you Paid Family Leave (PFL) benefits for the period from
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through
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, we need the following information:
1.
Did you provide family care during the period shown above?
 
If no, enter the date you stopped providing family care and explain why you stopped:
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2.
Did you work or earn any wages during the period shown above?
 
If yes, did you work part-time or full-time?
3.
Gross salary (before deductions including tips but excluding overtime) for the last full week you worked before your PFL began: (if you have more than one employer, please provide salary information for each employer on the back of this form including your name and Social Security number).
$
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6.
Was anyone else available to provide care during the period shown above?
 
If yes, please explain:
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I have reported on this form all money and wages I have received or will receive for the above certification period. My answers are true to the best of my knowledge.
Signature:Blank Space
Date:Blank Space
If your address and/or telephone number has changed, please enter the new information below.
If you have questions regarding this form, please call ‎1-877-238-4373 between the hours of 8:00 a.m. and 5:00 p.m.
PENALTIES:
California Unemployment Insurance Code (CUIC) provides for penalties of fine, imprisonment, and loss of benefit rights for fraud against the Employment Development Department (EDD).

DE 2580GF Rev. 3 (11-21) (INTRANET)