DI / DE 2522

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

Declaration of Individual Claiming Benefits Due an Incapacitated or Deceased Claimant

(COMPLETE BOTH SIDES OF THIS FORM)

 
Claimant SSN:
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Claimant Name:
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CED:
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*This Declaration may be completed by one of the following:
  • Legal heir of a deceased claimant.
  • Legally authorized representative of a physically or mentally incapacitated claimant.
  • The spouse of a physically or mentally incapacitated claimant, if there is no legally authorized representative.
  • The registered domestic partner of a physically or mentally incapacitated claimant, if there is no legally authorized representative.
  • The parent of an unmarried, physically or mentally incapacitated claimant, if there is no legally authorized representative.
I,
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NAME OF REPRESENTATIVE
, residing at
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STREET ADDRESS
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CITY, STATE, ZIP CODE
, declare that I am the
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*RELATIONSHIP/LEGALLY AUTHORIZED REPRESENTATIVE
of
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NAME OF CLAIMANT
, hereinafter "claimant."

I state that any and all State Disability Insurance (SDI) or Paid Family Leave (PFL) benefit payments which I may receive as representative of claimant will be used on behalf of and for the benefit of the claimant or his/her estate and for no other purpose. I hereby indemnify and hold harmless the California Employment Development Department (EDD), hereinafter "Department," for any misapplication of such benefit payments and for any loss, cost, damage, or liability which the Department may or will suffer by reason of delivering such benefit payments to me as representative of the claimant. I understand that the use of such payments by me on behalf of the claimant constitutes a release of any and all claims which claimant may have against Department for disability insurance (DI) or family leave benefits. I declare that I am authorized by law to claim benefits because there is no other legally authorized representative of claimant. If claiming benefits as the parent of an adult claimant, I declare that claimant is unmarried and has no registered domestic partner. If claiming benefits as the parent of an unmarried minor, I declare that claimant's estate value is less than $5,000. I further declare that I am legally entitled to claim any benefits due, owing, and payable to said claimant under the California Unemployment Insurance Code (CUIC) for the reason checked below.

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MONTH, DAY, YEAR
at
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CITY
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COUNTY
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STATE
I further declare that claimant was eligible to file for benefits provided by Division 1, Part 2 of the California Unemployment insurance Code (CUIC) and that claimant, by reason of his/her death, is not capable of making or filing a claim for such benefits. I understand that benefits may be paid to claimant's heir only for days up to and including the date of claimant's death.
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PHYSICIAN OR PRACTITIONER
that claimant is mentally incapable of making or filing a claim for disability insurance (DI) or family leave benefits.
Doctor's Certification: I hereby certify that the above-named claimant is under my care and that, based on my examination, claimant is mentally unable to make a claim for disability insurance (DI) or family leave benefits. I further certify that I am a   Blank Line   TYPE OF PHYSICIAN OR PRACTITIONER  duly authorized by the Employment Development Department (EDD).
 
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PRINT OR TYPE NAME AS SHOWN ON LICENSE
 
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SIGNATURE OF ATTENDING PHYSICIAN OR PRACTITIONER
 
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ADDRESS
 
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STATE LICENSE NUMBER
 
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TELEPHONE NUMBER
 
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DATE

DE 2522 Rev. 10 (10-10) (INTRANET)

SAMPLE, this page for reference only

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PHYSICIAN OR PRACTITIONER
that claimant is physically incapable of making or filing a claim for disability insurance (DI) or paid family leave (PFL) benefits.
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CLAIMANT
residing at
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ADDRESS
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CITY
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STATE
hereby appoint
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REPRESENTATIVE
as my true and lawful agent,
herein "representative," to file a claim for (check one)
in my name, to execute for me any documents required in connection with such claim, and to accept any benefits made payable to me, with full power of substitution or revocation. I instruct that my representative shall lawfully hold harmless the Employment Development Department (EDD) for any misapplication of benefit payments or any loss, cost, damage, or liability which the Department may suffer by reason thereof. Due to my inability to sign my name, I hereby authorize and direct my above-named representative to sign my name to this document.
Completed in the presence of myself and two witnesses.
 
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SIGNATURE OF CLAIMANT OR NAME OF CLAIMANT SIGNED BY REPRESENTATIVE
DO NOT PRINT
 
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DATE
By
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SIGNATURE OF REPRESENTATIVE
 
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SIGNATURE OF WITNESS
 
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SIGNATURE OF WITNESS
 
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ADDRESS
 
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ADDRESS
I understand that this Declaration is made for the sole purpose of obtaining such State Disability Insurance (SDI) or Paid Family Leave (PFL) benefits as are or may be payable to claimant. I accept the responsibilities and obligations arising from acting in behalf of claimant in accordance with the California Unemployment Insurance Code (CUIC) and authorized regulations pertaining thereto.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Executed at
,
CITY
,
COUNTY
.
STATE
 
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SIGNATURE OF REPRESENTATIVE
 
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DATE

DE 2522 Rev. 10 (10-10) (INTRANET)