DI / DE 5067

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Religious Exemption Certificate

This form is for requesting an exemption from State Disability Insurance (SDI) contributions from your wages based on your religious beliefs. Read the Certification Statement below.

If you agree with the statement:
  • Fill out and complete all the sections of this form.
  • Use your employer's business name from their quarterly contribution return and report of wages (continuation) (DE 9C). If you are unsure, check with your employer or supervisor.
See the last page of this form for more information on:
  • How to mail your form.
  • Eligibility requirements.
  • After your exemption is approved.
  • How to end your exemption.

Certification Statement

I certify that I depend on prayer for healing in line with my practice of the principles of the organization listed below. I request an exemption from having State Disability Insurance (SDI) contributions taken from my wages. I understand this exemption means I will not receive disability and Paid Family Leave (PFL) benefits.
Caption
Organization or DenominationBlank space
Street AddressBlank space
City, State, Zip CodeBlank space
Phone Number (including area code)Blank space
Your Name (Please Print)
First NameBlank space Middle InitialBlank space Last NameBlank space
Social Security NumberBlank space Phone Number (Including Area Code)Blank space
Street Address and Apartment Number or PO BoxBlank space
City Blank space State Blank space Zip CodeBlank space

DE 5067 Rev. 14 (2-25) (INTRANET)

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EDD Employment Development Department State of California Logo

 
For Department Use Only
Effective:
Blank Line
VP:
Yes  No
Approved:
Blank Line
Initials:
Blank Line

DE 5067 Rev. 14 (2-25) (INTRANET)

SAMPLE, this page for reference only

How to Mail Your Religious Exemption Certificate

  1. Make a copy of this certificate for your records.
  2. Mail the original certificate and a copy of your religious group’s tenets to:
    Employment Development Department Disability Insurance Branch PO Box 826880 Sacramento, CA 94280-0001

Eligibility Requirements

Your request will be approved only if you follow the faith or teaching of a recognized religious sect, denomination, or organization whose creed, tenets, or principles require prayer for healing.

After You’re Approved

Your religious exemption will begin no earlier than the first day of the calendar quarter when we receive your form. If you want your exemption to start in the previous calendar quarter or the next quarter, attach a note to this form.

The start date in a previous calendar quarter only applies to wages that have not been reported.

We will let your employer know that your State Disability Insurance (SDI) contributions should not be withheld from your wages. If you change employers, you will need to file a new religious exemption form.

How to End Your Religious Exemption

Fill out and mail your completed Revocation of Religious Exemption Certificate (DE 6341) to:
Employment Development Department Disability Insurance Branch PO Box 826880 Sacramento, CA 94280-0001
The EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Requests for services, aids, and/or alternate formats need to be made by calling 1-866-490-8879 (voice). TTY users, please call the California Relay Services at 711.

DE 5067 Rev. 14 (2-25) (INTRANET)