DI / DE 2500A

SAMPLE, this page for reference only

RETURN TO:

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EDD Employment Development Department State of California Logo

‎(800) 480-3287

CLAIM FOR CONTINUED DISABILITY BENEFITS

EDD Customer Account Number (EDDCAN) CLAIM ID SSN/ECN CED
Blank Space Blank Space Blank Space Blank Space

No additional payments will be authorized unless you complete and return this form. For faster processing, you can complete and submit this form online at www.edd.ca.gov If you submit online, you do not have to mail this form.
When completing this form, PLEASE PRINT WITH BLACK INK.

This claim certification covers the period starting Blank Line ending Blank Line *
  • Please check the appropriate box in Section 1 and complete Section 2
  • If your address or telephone number has changed, please complete Section 3
  • Sign and date Section 4 and return this form within the time limits shown for the box you checked in Section 1
WARNING: You may lose benefits if this claim is not returned within:
  1. 1) 20 days starting on the "ENDING" date above*
  2. OR
  3. 2 ) 20 days after the day you receive this claim if the "ENDING" date has passed*
* If you return this claim before the "ENDING" date of the certification period above, you will only be paid to the day before the signature date or postmarked date, whichever comes first.

Section 1 – Disability Status.

Sign and date Section 4, and return this form no earlier than Blank Line , but no later than (i.e., 20 days from and including the "ending" date above). If that date has passed, sign, date, and return this form immediately.
Check only one

Section 2 – Money, Wages, or Workers' Compensation.

You must report payments of any type, excluding vacation pay, that you have received or will receive from your employer(s) for the period of this claim certification. (Examples: wages, sick leave pay, pension pay, a loan, a gift, military reserve or National Guard pay.) Also report for this period any cash payment received under a Workers’ Compensation program. DO NOT REPORT MONEY YOU RECEIVED FROM STATE DISABILITY INSURANCE (SDI). If you received no money from your employer (besides vacation pay) and no money under a Workers' Compensation program, check "No" and proceed to the remaining sections on this form.
Did or will you receive employer wages or Workers’ Compensation benefits during your disability period?
If you answered yes, please complete the wage section on the following page.
ADDITIONAL QUESTIONS AND SIGNATURE REQUIRED ON REVERSE SIDE

DE 2500A Rev. 3 (3-12) (INTRANET)

SAMPLE, this page for reference only

Section 2 – Continued

Wages Paid By
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Area Code and Telephone Number
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Extension
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Number/Street/Suite#
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City
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State
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Zip or Postal Code
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Country (If Not U.S.A.)
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GROSS DOLLAR AMOUNT RECEIVED: $ Blank Line PAID FROM MM/DD/YYYY THROUGH MM/DD/YYYY
PAYMENT TYPE RECEIVED:

Section 3 – If you have changed your address or telephone number, please complete the following:
Has your address/phone number changed?
Which Address(es) changed?
Mailing: (PO Box Users: Your residence address is required if different from your mailing address)
PO Box Or Number/Street/Apartment, Suite, Space#, Or PMB# (Private Mail Box)
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City
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State
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Zip Or Postal Code
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Country (If Not U.S.A.)
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Residence:
Number/Street/Apartment Or Space#
Blank line
City
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State
Blank line
 Zip Or Postal Code
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Country (If Not U.S.A.)
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Which phone number(s) changed?
Home phone
Area Code and Telephone Number
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Cell phone
Area Code and Telephone Number
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Section 4 – Declaration and Signature.
I declare under penalty of perjury that the foregoing statement is to the best of my knowledge and belief true, correct, and complete. I have shown above all money or wages I received during the period covered by this claim. 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 and that such violation is punishable by imprisonment or fine or both.
Blank line
Your signature (Do Not Print)
Date signed
MM/DD/YYYY

DE 2500A Rev. 3 (3-12) (INTRANET)