Claim for Paid Family Leave (PFL) Benefits
Paid Family Leave (PFL), a worker-funded program, provides benefits to eligible workers who have a full or
partial loss of wages due to the need to care for a seriously ill family member, to bond with a new child, or
to participate in a qualifying event as a result of your spouse, registered domestic partner, parent, or child’s
military deployment to a foreign country.
Please read instruction and information pages (A through F) before completing the enclosed forms.
For faster processing, file your claim using SDI Online (edd.ca.gov/disability/sdi_online.htm). If you file online,
do NOT mail this form to the Employment Development Department (EDD).
Do not complete this form if you are insured by a Voluntary Plan. Ask your employer for the proper forms.
If you cannot complete this form due to a disability, or if you are an authorized representative filing for benefits on
behalf of an incapacitated or deceased claimant, call 1-877-238-4373.
HOW TO COMPLETE THIS FORM
• Use black ink only.
• Type or write clearly within the boxes provided.
• Enter your Social Security number on all pages of the claim form including attachments.
• Do not fax the form.
• Mail the completed form to the EDD in the envelope provided. Submit your claim no earlier than the
first day your family leave begins but no later than 41 days after your family leave begins. You may lose
benefits if your claim is late.
1. Complete ALL items on the enclosed “PART A – STATEMENT OF CLAIMANT” and sign box A25. Errors
or missing information may cause your claim to be returned and delay payment. For box A8, the United
States Postal Service will not deliver mail to a private mail box unless it is preceded by the initials “PMB.”
2. For bonding, also complete “PART B – BONDING CERTIFICATION” and enclose a copy of one of the
documents listed in box B10. Do not complete Part B if you are filing to care for a family member.
3. For care:
a. Have the care recipient complete and sign “PART C – STATEMENT OF CARE RECIPIENT.” If the
care recipient is a minor or incapacitated, an authorized representative may complete this part.
b. Have the treating physician/practitioner complete and sign “PART D – PHYSICIAN/
PRACTITIONER’S CERTIFICATION.” Certification may be made by a licensed physician or
practitioner authorized to certify to a patient’s disability or serious health condition pursuant to
California Unemployment Insurance Code, section 2708. If the care recipient is under the care of
an accredited religious practitioner, obtain a Practitioner’s Certification for Paid Family Leave (PFL)
Benefits (DE 2502F) by calling 1-877-238-4373. Rubber stamp signatures are not accepted.
4. For participating in a qualifying event, also complete “PART E – MILITARY ASSIST CERTIFICATION” and
enclose a copy of one of the documents listed in Box E10.
5. You should carefully decide the date you want your claim to begin because it may affect your benefit
amount. See “YOUR BENEFIT AMOUNTS” on page B for information.
6. Place the completed, signed form(s) in the envelope provided. Claims are generally processed within 14
days after the EDD receives a completed claim.
o For bonding, a claim is complete when parts A and B, and supporting documents are received.
o For care, a claim is complete when parts A, C, and D are received.
o For military assist, a claim is complete when Parts A, E and supporting documentation are received.
7. Keep these instructions and information pages (A through F) for future reference.
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 Service at 711.
DE 2501F Rev. 5 (12-20) (INTERNET) Instruction & Information A
Page 1 of 11
BASIC ELIGIBILITY. PFL benefits can be paid only after you
meet all of the following requirements:
• You must be unable to do your regular or customary work
due to the need to provide care, to bond with a new child,
or to participate in a qualifying event.
• You must be employed or actively looking for work at the
time your family leave begins.
• If working, you must have lost wages because you were
caring for a seriously ill family member, bonding with a new
child, or participating in a qualifying event.
• You must have earned at least $300 from which State
Disability Insurance (SDI) deductions were withheld during
a previous period. (See “YOUR BENEFIT AMOUNTS” in the
next column.)
• You must complete and mail a claim form within 41 days
after the first day your family leave begins or you may lose
benefits.
In addition, the following requirements must be met only if your
PFL claim is to care for a seriously ill family member:
• The care recipient must be your child, parent, spouse,
registered domestic partner, grandparent, grandchild, sibling,
or parent-in-law.
• The care recipient must be under the continuing treatment
or supervision of a licensed physician/practitioner or
accredited religious practitioner while you are receiving
benefits.
• The care recipient’s physician/practitioner must complete
the certification that he/she requires care. If the care
recipient is under the care of a religious practitioner, request
a Practitioner’s Certification for Paid Family Leave (PFL)
Benefits (DE 2502F) from the PFL office. Certification by a
religious practitioner is acceptable only if the practitioner has
been accredited by the EDD.
The following requirements must also be met only if your PFL
claim is to bond with a new child:
• Your leave must take place within 12 months of the birth,
adoption, or foster care placement of the child.
• The new child must be either your or your registered
domestic partner’s biological child, adopted child, or foster
child.
The following requirements must also be met only if your PFL
claim is to assist a military family member:
• Provide proof of covered active duty or call to covered active
duty documentation of the family member.
• Provide the qualifying event for leave and any supporting
documentation. For example taking the leave to make
financial or child care arrangements, or to attend an event
sponsored by the military. A document supporting the reason
for leave may be required.
INELIGIBILITY. You may apply for benefits even if you are not
sure you are eligible. If you are found to be ineligible for all or
part of a period claimed, you will be notified of the ineligible
period and the reason. You may not be eligible for PFL benefits if:
• You are claiming or receiving Unemployment Insurance (UI)
or Disability Insurance (DI) benefits.
• You are receiving workers’ compensation benefits at a
weekly rate equal to or greater than the PFL rate.
• You are in jail, prison, or any other facility.
FRAUD. Under sections 1143, 2101, 2116, 2122, and 3305 of
the California Unemployment Insurance Code, it is a violation
to willfully make a false statement or knowingly conceal a
material fact in order to obtain the payment of any benefits.
Such violation is punishable by imprisonment, and/or by a fine
not exceeding $20,000, or both. To detect and discourage fraud,
the EDD continually monitors claims, vigorously investigates
suspicious activity, and will seek restitution and conviction
through prosecution.
YOUR RESPONSIBILITIES
• File your claim and other forms completely, accurately, and
in a timely manner. If a form is late, include with the form a
written explanation of the reason(s).
• Carefully read the instructions on this and all other forms
you receive from PFL. If you are not sure what is required,
contact the PFL office.
• Call or report in writing to the PFL office any:
o Change of address or telephone number.
o Return to part-time or full-time work.
o Need for care or bonding to stop.
o Income you receive.
• Include your name and Social Security number on all
correspondence.
YOUR RIGHTS. Information about your claim will be kept
confidential, except for the purposes allowed by law. California
Civil Code, section 1798.34, gives you the right to inspect any
personal records maintained about you by the EDD. Section
1798.35 permits you to request that the record be corrected if you
believe it is not accurate, relevant, timely, or complete. Certain
types of information that would generally be considered personal
are exempt from disclosure to you: medical or psychological
records where knowledge of the contents might be harmful to the
subject (Civil Code, section 1798.40); records of active criminal,
civil, or administrative investigations (Civil Code, section 1798.40).
Additionally, the EDD will not disclose or provide copies of care
recipients’ medical information to care providers. If you are denied
access to records which you believe you have a right to inspect
or if your request to amend your records is refused, you may file
an appeal with the PFL office. You may request a copy of your
file by calling the telephone number shown on your Notice of
Computation (DE 429D).
You also have the right to appeal any disqualification,
overpayment, or penalty. Specific instructions on how to appeal
will be provided on any appealable document you receive.
YOUR BENEFIT AMOUNTS. Your claim begins on the date your
family leave began. The EDD calculates your weekly benefit
amount using your base period. The date your family leave began
determines your base period. You may not change the beginning
date of your claim or adjust your base period after you have
established a valid claim.
This base period covers 12 months and is divided into four
consecutive quarters. Your base period includes wages subject to
SDI tax that you were paid approximately 5 to 18 months before
your PFL claim begins. Your base period does not include wages
being paid at the time family leave begins. For a PFL claim to be
valid, you must have earned at least $300 in wages in the base
period. Using the following, you may determine the base period.
• If your claim begins in January, February, or March, your base
period is the 12 months ending last September 30.
• If your claim begins in April, May, or June, your base period is
the 12 months ending last December 31.
• If your claim begins in July, August, or September, your base
period is the 12 months ending last March 31.
• If your claim begins in October, November, or December, your
base period is the 12 months ending last June 30.
The quarter of your base period in which you were paid the highest
wages determines your weekly benefit amount.
• For more information about your benefit amount visit
edd.ca.gov/Disability/Calculating_PFL_Benefit_Payment_
Amounts.htm.
Contact the PFL office to inquire about benefits and to provide
additional information if your situation fits any of these
circumstances:
• If you do not have sufficient base period wages, you may be
able to establish a valid claim by using a later beginning date.
• If you do not have enough base period wages and you were
actively seeking work for 60 days or more in any quarter of the
base period, you may be able to substitute wages paid in prior
quarters.
• If during your base period you served in the military, received
workers’ compensation benefits, or did not work because of a
labor dispute.
DE 2501F Rev. 5 (12-20) (INTERNET) Instruction & Information
B
Page 2 of 11
DE 2501F Rev. 5 (12-20) (INTERNET) Instruction & Information C
Each person receiving PFL benefits will receive a 1099G form to
include with his/her federal income tax return. PFL benefits are not
subject to California income taxes. For 1099G inquiries, please call
1-800-795-0193.
OVERPAYMENT. An overpayment results when you receive PFL
benefit payments you were not eligible to receive. Once the EDD
determines that you were overpaid, the PFL office will contact you
to explain the reason for your overpayment. It is important that you
complete and return all information requests, as there are some
instances when an overpayment can be waived. If it is determined
that you were overpaid and the overpayment cannot be waived,
you must repay this money. Payments issued after an overpayment
is established may be reduced by 25 to 100 percent to collect your
overpayment. You will receive a Notice of Overpayment Offset
(DE 826), if your weekly benefit amount is reduced due to a DI,
PFL, or UI overpayment.
DISQUALIFICATION. All available information will be considered
before issuing a benefit payment or disqualifying your claim.
Benefits will be paid only for the days to which you are eligible. If
payment of benefits is denied or reduced, you will receive a written
notice stating the reason for the disqualification.
If you deliberately report incorrect information or if you willfully
omit or withhold information, false statement disqualifications of up
to 92 days will be assessed. This may apply if you receive a payment
that you know includes days for which you should not be paid,
such as days after you returned to work. In addition, any resulting
overpayment will be increased by a 30 percent penalty assessment.
SPECIAL CIRCUMSTANCES
Pregnancy. Mothers who are receiving DI benefits for a
pregnancy-related disability and have delivered their child may
be eligible for PFL benefits to bond with their new child. A Claim
for Paid Family Leave (PFL) Benefits - New Mother (DE 2501FP)
will automatically be sent to these new mothers at the end of their
pregnancy-related DI claims.
Child Support Obligations. Contact the District Attorney’s office
administering the court order.
Spousal or Parental Support Obligations. Questions should be
directed to the District Attorney’s office administering the court
order.
Job Training. Contact an America’s Job Center of California
SM
(1-877-872-5627 or servicelocator.org) for services available in
your area.
Seeking Work. Contact the EDD for information and assistance
concerning employment opportunities and UI benefits.
• To register for employment, visit caljobs.ca.gov.
• To apply for UI benefits, visit edd.ca.gov/unemployment.
Death of Claimant. If a person receiving PFL benefits dies, an heir
or legal representative should report the death to PFL. Benefits are
payable through the date of death, if otherwise eligible.
Death of Care or Bonding Recipient. If the person for whom you
are caring for or the child with whom you are bonding with dies,
report the death to PFL at 1-877-238-4373. Benefits are payable
through the date of death, if otherwise eligible.
Job Benefits and Protection Programs. The Family and Medical
Leave Act (FMLA) and California Family Rights Act (CFRA) offer
job protected leave to “eligible” employees for certain family
and medical reasons. For more information about FMLA, call
1-866-487-9293 or visit dol.gov/whd/fmla. For more information
on CFRA, call 1-800-884-1684 or visit dfeh.ca.gov.
HOW BENEFITS ARE PAID. When your claim is received, the PFL
office will notify you of your weekly benefit amount and request
any additional information needed to determine your eligibility. If
you are eligible to receive benefits, payments are issued through
the EDD Debit Card
SM
. You do not have to accept the EDD Debit
Card. The EDD Debit Card is the fastest and most secure way to
receive your benefits. You have an option to receive your benefit
payments by check. The majority of claims are processed and
payments issued within 14 days of receipt of a correctly completed
claim.
Payments will be issued automatically. You will be paid 1/7 of
your weekly benefit amount for each calendar day you are eligible
unless benefits are reduced for some reason. See “BENEFIT
REDUCTIONS” below.
BENEFIT REDUCTIONS. Under certain circumstances, you may
not be eligible for a period of your claim or you may be entitled
only to partial benefits. The EDD will determine whether or not
benefits must be reduced. The types of income shown in the
following list should be reported to the EDD even though they
may not always affect your benefits. Failure to report your income
could result in an overpayment, penalties, and/or a false statement
disqualification.
• Sick leave pay
• Vacation pay
• Self-employment income
• Military pay
• Commissions
• Wages, including modified duty wages
• Residuals
• Bonuses
• Workers’ compensation benefits
• Holiday pay
• Paid time off
• Part-time work income
In addition, your benefits may be reduced because of a prior
Unemployment Insurance (UI), Disability Insurance (DI), or PFL
overpayment or for delinquent court-ordered child or spousal
support payments.
BENEFIT INTERRUPTION and TERMINATION. You will see
“Notice of Exhaustion of Paid Family Leave Benefits” on the
Electronic Benefit Payment (EBP) Notification (DE 2500E) when:
• You have been paid to the date the care recipient no
longer requires care, as estimated by the care recipient’s
physician/practitioner. If the care recipient still requires care,
complete and sign the PFL Claimant’s Certification portion and
ask the care recipient’s physician/practitioner to complete and
mail the Physician/Practitioner’s Supplementary Certificate
(DE 2525XFA).
• The care recipient has recovered. If you return to work and the
care recipient again requires care, immediately submit a new
claim form and report the dates you worked.
A Notice of Exhaustion of Paid Family Leave Benefits (DE 2525AF)
will be issued when records show you have been paid the
maximum amount of PFL benefits.
TAXABILITY of BENEFITS. PFL benefits are subject to federal
income taxes and will be reported to the Internal Revenue Service.
Page 3 of 11
DE 2501F Rev. 5 (12-20) (INTERNET) Instruction & Information D
EDD Debit Card Fee Disclosures
Monthly Fee Per purchase ATM withdrawal Cash reload
$0 $0 $0 in-network N/A
$1.00** out-of-network
ATM balance inquiry $0
Customer service $0 per call
Inactivity $0
We charge 5 other types of fees. Here are some of them:
Replacement card, express delivery $10.00
Each international transaction 2%
*This document entitled ‘Fee Disclosure and Other Important Disclosures’ is included with, and incorporated
in, the California Employment Development Department Debit Card Account Agreement.
**Fees can be lower depending on how and where this card is used.
See the materials you received with your card for free ways to access your funds and balance information.
No overdraft/credit features.
Your funds are eligible for FDIC insurance.
For more information about prepaid cards, visit cfpb.gov/prepaid.
Find details and conditions for all fees and services in the cardholder agreement.
Page 4 of 11
DE 2501F Rev. 5 (12-20) (INTERNET) Instruction & Information E
All Fees Amount Details
Spend Money
Per purchase with PIN $0
Per purchase with signature $0
Get Cash in the U.S.
ATM withdrawal, in-network $0 “In Network” refers to Bank of America ATMs. Locations can
be found at www.bankofamerica.com/eddcard. You will not be
charged a fee by Bank of America.
ATM withdrawal,
out-of-network
$1.00 You will be charged this fee after 2 free for each deposit. “Out of
Network” refers to all the ATMs outside of Bank of America ATMs.
You may also be charged a fee by the ATM operator even if you do
not complete a transaction.*
Bank teller cash withdrawal $0 Available at financial institutions that accept Visa cards. Limited to
available balance only.
Emergency cash transfer,
domestic
$15.00 All emergency cash transfers must be initiated through the Prepaid
Debit Card Customer Service Center.
Information
Customer service $0
Online account information $0
Account alert service $0
ATM balance inquiry $0
Using your card outside the U.S.
Each international
transaction
2% Of total U.S. Dollar amount of transaction
International ATM
withdrawal
$1.00 This is the Bank of America fee. You may also be charged a fee by
the ATM operator, even if you do not complete a transaction.
Other
Online funds transfer $0
Replacement card, domestic $0
Replacement card, express
delivery
$10.00 Additional charge
Replacement card,
international
$10.00 Additional charge
Inactive account $0
*ATM owners may impose an additional “convenience fee” or “surcharge fee” for certain ATM transactions (a sign should be posted at the
ATM to indicate additional fees); however you will not be charged any additional convenience fee or surcharge fee at a Bank of America
ATM. A Bank of America ATM means an ATM that prominently displays the Bank of America name and logo.
Your funds are eligible for FDIC insurance. Your funds are insured up to $250,000 by the FDIC in the event Bank of America, N.A. fails, if
specific deposit insurance requirements are met. See fdic.gov/deposit/deposits/prepaid.html for details.
No overdraft/credit feature.
Contact Bank of America by calling 1.866.692.9374, 1.866.656.5913 (TTY), or 1.423.262.1650 (Collect, when calling outside the U.S.), by
mail at Bank of America, P.O. Box 8488, Gray, TN 37615-8488, or visit www.bankofamerica.com/eddcard.
For general information about prepaid accounts, visit cfpb.gov/prepaid.
If you have a complaint about a prepaid account, call the Consumer Financial Protection Bureau at 1-855-411-2372 or visit
cfpb.gov/complaint.
Page 5 of 11
FEDERAL PRIVACY ACT. The EDD requires disclosure of Social Security numbers to comply with California Unemployment Insurance
Code, sections 1253 and 2627; with California Code of Regulations, Title 22, sections 1085, 1088, and 1326; with Code of Federal
Regulations, Title 20, Part 604; and with U.S. Code, Title 8, sections 1621, 1641, and 1642.
INFORMATION COLLECTION AND ACCESS. State law requires the following information to be provided when collecting information
from individuals:
Agency Name:
Employment Development Department (EDD)
Title of Official Responsible for Information Maintenance:
Manager, EDD Paid Family Leave Office
Local Contact Person:
Manager, EDD Paid Family Leave Office
Contact Information:
You may contact Paid Family Leave by calling 1-877-238-4373.
A list of Paid Family Leave local office locations can be found by
visiting edd.ca.gov/disability/Contact_DI.htm. The address and phone number of Paid
Family Leave will also appear on the Notice of Computation (DE 429D) issued at the
time your benefit determination is made.
Maintenance of the information is authorized by:
California Unemployment Insurance Code, sections 2601 through 3306.
California Code of Regulations, Title 22, sections 2706-2, 2706-3, and 2708-1.
Consequences of not providing all or any part of the requested information:
• Failure to supply any or all information may cause delay in issuing benefit payments or may cause you to be denied benefits
to which you are entitled.
• If you willfully make a false statement or representation or knowingly withhold a material fact to obtain or increase any
benefit or payment, the EDD will disqualify you from receiving benefits and/or services and may initiate criminal prosecution
against you.
Principal purpose(s) for which the information is to be used:
• To determine eligibility for Paid Family Leave benefits.
• To be summarized and published in statistical form for the use and information of government agencies and the public.
(Neither your name and identification nor the name and identification of the care, bonding or military assist recipient will
appear in publications.)
• To be used to locate persons who are being sought for failure to provide child or spousal support.
• To be used by other governmental agencies to determine eligibility for public social services under the provisions of California
Welfare and Institutions Code, Division 9.
• To be used by the EDD to carry out its responsibilities under the California Unemployment Insurance Code.
• To be exchanged pursuant to California Unemployment Insurance Code, section 322, and California Civil Code, section
1798.24, with other governmental departments and agencies, both federal and state, which are concerned with any of the
following:
(1) Administration of an Unemployment Insurance program.
(2) Collection of taxes which may be used to finance Unemployment Insurance or State Disability Insurance.
(3) Relief of unemployed or destitute individuals.
(4) Investigation of labor law violations or allegations of unlawful employment discrimination.
(5) The hearing of workers’ compensation appeals.
(6) Whenever necessary to permit a state agency to carry out its mandated responsibilities where the use to which the
information will be put is compatible with the purpose for which it was gathered.
(7) When mandated by state or federal law. Disclosures under California Unemployment Insurance Code, section 322,
will be made only in those instances in which it furthers the administration of the programs mandated by that Code.
• Pursuant to California Unemployment Insurance Code, sections 1095 and 2714, information may be revealed to the extent
necessary for the administration of public social services or to the Director of Social Services or his/her representatives.
• Information shall be disclosed to authorized agencies in accordance with California Unemployment Insurance Code,
sections 1095 and 2714.
DE 2501F Rev. 5 (12-20) (INTERNET) Instruction & Information
F
Page 6 of 11
Claim for Paid Family Leave
(PFL) Benefits
PART A – STATEMENT OF CLAIMANT (CARE, BONDING, or MILITARY ASSIST PROVIDER)
A1. YOUR SOCIAL SECURITY NO.
A2. YOUR DATE OF BIRTH
M M D D Y Y Y Y
A3. LANGUAGE YOU PREFER TO USE
ENGLISH ESPAÑOL OTHER (PRINT BELOW)
A4. YOUR LEGAL NAME
FIRST NAME MI LAST NAME
A5. YOUR GENDER
MALE FEMALE
A6. YOUR TELEPHONE NUMBER
A8. YOUR MAILING ADDRESS (TO RECEIVE MAIL AT A PRIVATE MAIL BOX—NOT A US POSTAL SERVICE BOX—YOU MUST SHOW THE NUMBER IN THE “PMB#” SPACE.) PMB# (IF APPLICABLE)
A9. NAME OF YOUR EMPLOYER MAILING ADDRESS
CITY STATE/PROV. ZIP
OR POSTAL CODE COUNTRY (IF NOT U.S.A.)
CITY STATE/PROV. ZIP OR POSTAL CODE EMPLOYER’S PHONE NUMBER
A7. OTHER LAST NAMES, IF ANY, UNDER WHICH YOU HAVE WORKED
A10. DATE YOU LAST WORKED
M M D D Y Y Y Y
A14. WHY DID YOU OR WILL YOU REDUCE YOUR WORK HOURS OR STOP WORKING?
A15. WHAT IS YOUR OCCUPATION?
A11. DATE YOU WANT YOUR
PFL CLAIM TO BEGIN
M M D D Y Y Y Y
A12. DATE YOU RETURNED OR
WILL RETURN TO WORK
M M D D Y Y Y Y
A13. DID YOU WORK OR WILL YOU CONTINUE TO
WORK DURING YOUR FAMILY LEAVE PERIOD?
NO YES
A17. LEGAL NAME OF CARE, BONDING, OR MILITARY ASSIST RECIPIENT (FIRST / MIDDLE INITIAL / LAST)
A18. THE ABOVE-NAMED CARE, BONDING, OR MILITARY ASSIST RECIPIENT IS YOUR:
REGISTERED DOMESTIC PARENT GRAND GRAND
CHILD SPOUSE PARTNER PARENT IN-LAW PARENT CHILD SIBLING OTHER (EXPLAIN)
A19. IS ANY OTHER FAMILY MEMBER READY, WILLING, AND ABLE AND
AVAILABLE TO PROVIDE CARE FOR THE SAME PERIOD YOU ARE
NO YES CLAIMING PFL BENEFITS?
A21. DO YOU HAVE MORE
THAN ONE EMPLOYER?
NO YES
A22. IF YOUR EMPLOYER(S) CONTINUED OR WILL CONTINUE TO PAY YOU
DURING YOUR FAMILY LEAVE, INDICATE TYPE OF PAY:
SICK VACATION OTHER (EXPLAIN)
A20. HAVE YOU CLAIMED OR DO YOU PLAN TO CLAIM WORKERS’ COMPENSATION
BENEFITS FOR ANY PORTION OF THE PERIOD COVERED BY THIS CLAIM?
NO YES
A23. MAY WE DISCLOSE BENEFIT PAYMENT
INFORMATION TO YOUR EMPLOYER(S)?
NO YES
A24. AT ANY TIME DURING YOUR PFL LEAVE, WERE YOU IN THE CUSTODY OF LAW ENFORCEMENT AUTHORITIES BECAUSE YOU WERE
CONVICTED OF VIOLATING A LAW OR ORDINANCE?..................................................................................................................................
A25. Declaration and Signature. By my signature on this claim statement I (1) claim Paid Family Leave benefits and certify that throughout the period covered by this claim I was providing care for,
bonding with, or participating in a qualifying event with the recipient named above (2) authorize EDD to release my personal information as shown on this claim to the care recipient’s treating physician as they
are respectively listed in Part C and Part D of this claim (3) authorize my employer(s) to disclose EDD all facts concerning my employment that are within their knowledge and (4) authorize release and use of
information as stated in the Information Collection and Access portion of this 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 perjury that the foregoing statement including any accompanying statements 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 the claim, whichever is later.
NO YES
Claimant’s Signature (DO NOT PRINT) If signature is made by mark (X), please place mark here.* Date Signed ( M M | D D | Y Y Y Y)
*If your signature is made by mark (X), it must be attested by two witnesses with their addresses
1
st
Witness Signature and Address 2
nd
Witness Signature and Address
CARE FOR
FAMILY MEMBER
BOND WITH
CHILD
MILITARY
ASSIST OTHER (EXPLAIN)
A16. SELECT YOUR PREFERRED
PAYMENT METHOD
o
EDD DEBIT CARD
SM
o
CHECK
DE 2501F Rev. 5 (12-20) (INTERNET)
Page 7 of 11
SAMPLE, this page for reference only
000000000
999 0236789
12012015 12162015 01272016
12162015
PASTRY CHEF
COOKIE
Sample Claimant
CLAIMANTA
499 3111111
123 ANY STREET
ROADRUNNER PASTRIES
ANYWHERE
647 ARMISTICE WAY
ANYTOWN
66222
12345
CA
CA
SAMPLE CLAIMANT
01011900 X
X
X
X
X
X
X X
X
X
PART B – BONDING CERTIFICATION (TO BE COMPLETED BY PERSON CLAIMING PFL BENEFITS TO BOND WITH A CHILD)
B1. YOUR SOCIAL
SECURITY NUMBER
B4. YOUR LEGAL LAST NAME (NEEDED IN CASE PAGES OF THIS
CLAIM BECOME SEPARATED)
B2. DATE OF FOSTER CARE OR
ADOPTION PLACEMENT
M M D D Y Y Y Y
B3. CHILD NAMED IN B8 IS MY
BIOLOGICAL FOSTER ADOPTED
CHILD STEPCHILD CHILD CHILD OTHER
B5. CHILD’S SOCIAL SECURITY
NUMBER
(IF AVAILABLE)
B6. CHILD’S DATE OF BIRTH
M M D D Y Y Y Y
B7. CHILD’S GENDER
MALE FEMALE
B8. LEGAL NAME OF CHILD (FIRST MIDDLE INITIAL LAST)
C4. LEGAL NAME OF CARE RECIPIENT (FIRST MIDDLE INITIAL LAST)
B9. CHILD’S RESIDENCE ADDRESS (IF DIFFERENT FROM CLAIMANT’S)
C5. CARE RECIPIENT’S RESIDENCE ADDRESS
C7. Authorized Representative signing on behalf of care recipient must complete the following: I,______________________________________ , represent the care or bonding recipient
in this matter as authorized by parental right power of attorney (attach copy) court order (attach copy) (For spouse or domestic partner, contact EDD.)
Authorized Representative’s Signature (DO NOT PRINT)
B10. AS EVIDENCE OF THE RELATIONSHIP IN B3, CHECK ONE OF THE FOLLOWING AND ATTACH A COPY OF THE DOCUMENT CHECKED.
(DO NOT SEND ORIGINAL DOCUMENT. IT WILL NOT BE RETURNED.)
CHILD’S BIRTH CERTIFICATE ADOPTIVE PLACEMENT AGREEMENT, AD-907
DECLARATION OF PATERNITY, CS-909 INDEPENDENT ADOPTION PLACEMENT AGREEMENT, AD-924
FOSTER CARE PLACEMENT RECORD, SOC-815 OTHER
CITY STATE/PROV. ZIP
OR POSTAL CODE COUNTRY (IF NOT U.S.A.)
CITY STATE/PROV. ZIP OR POSTAL CODE COUNTRY (IF NOT U.S.A.)
B11. Declaration and Signature. By my signature on this bonding certification, I authorize the medical provider, adoption agency, adoption party(ies), or foster care placement agency to
disclose to the Employment Development Department all facts concerning the birth, adoption, or foster care placement of the above-named child. 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 perjury
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 the claim, whichever is later.
Original Signature of Bonding Claimant – RUBBER STAMP IS NOT ACCEPTABLE
Care Recipient’s Signature ( DO NOT PRINT)
Date Signed ( M M | D D | Y Y Y Y)
Date Signed (
M M | D D | Y Y Y Y)
Date Signed (
M M | D D | Y Y Y Y)
PART C – STATEMENT OF (MAY BE COMPLETED BY CLAIMANT IF CARE RECIPIENT IS MENTALLY OR PHYSICALLY UNABLE TO DO SO.
CARE RECIPIENT
MUST BE SIGNED BY CARE RECIPIENT OR CARE RECIPIENT’S AUTHORIZED REPRESENTATIVE.)
C1. RECIPIENT’S DATE OF BIRTH
M M D D Y Y Y Y
C2. RECIPIENT’S TELEPHONE NUMBER
C3. RECIPIENT’S GENDER
MALE FEMALE
C6. CONFIRMATION OF MEDICAL DISCLOSURE AUTHORIZATION. I authorize my
physician/practitioner to disclose my current personal health information to my care provider
and to the California Employment Development Department (EDD). I further understand that
copies of my signature below are as valid as the original.
DE 2501F Rev. 5 (12-20) (INTERNET)
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000000000
12012015
12162015
CLAIMANT
COOKIE A CLAIMANT
X
X
X
Sample Claimant
Medical certifications must be completed by a licensed physician or practitioner
authorized to certify to a patients disability/serious health condition pursuant to
California Unemployment Insurance Code Section 2708.
INSTRUCTIONS FOR COMPLETING THIS FORM:
Please complete the information in the spaces provided in UPPER CASE using black ink. Do not use special characters ( - , . / ‘ ).
If handwritten, print each letter or number in a separate box. Ignore the boxes provided if using a typewriter or printer.
PART D – PHYSICIAN/PRACTITIONER’S CERTIFICATION (DO NOT COMPLETE THIS PART IF YOU ARE BONDING OR PARTICIPATING IN A
QUALIFYING EVENT.)
D1. PFL CLAIMANT’S (CARE
PROVIDER’S) SOCIAL
SECURITY NUMBER
D2. PFL CLAIMANT’S NAME (FIRST MIDDLE INITIAL LAST)
D3. PATIENT’S DATE OF BIRTH
M M D D Y Y Y Y
D10. FIRST DATE CARE NEEDED
M M D D Y Y Y Y
D11. DATE YOU EXPECT RECOVERY
M M D D Y Y Y Y NEVER
D12. DATE YOU ESTIMATE PATIENT WILL NO LONGER
REQUIRE CARE BY THE CLAIMANT
M M D D Y Y Y Y PERMANANT
D7. PRIMARY ICD CODE
D9. DATE PATIENT’S CONDITION COMMENCED
M M D D Y Y Y Y
D8. SECONDARY ICD CODES
D4. DOES YOUR PATIENT REQUIRE CARE BY THE CLAIMANT?
NO (SKIP TO D15) YES
D5. PATIENT’S NAME (FIRST MIDDLE INITIAL LAST)
D17. PHYSICIAN/PRACTITIONER’S NAME (FIRST MIDDLE INITIAL LAST)
D13. APPROXIMATELY HOW MANY TOTAL HOURS PER DAY WILL PATIENT REQUIRE CLAIMANT?
HOURS COMMENTS
D14. WOULD DISCLOSURE OF THIS CERTIFICATE TO YOUR PATIENT BE MEDICALLY OR PSYCHOLOGICALLY DETRIMENTAL? .........................
D15. PHYSICIAN/PRACTITIONER’S LICENSE NUMBER
D19. TYPE OF PHYSICIAN/PRACTITIONER
D21. PHYSICIAN/PRACTITIONER’S Certification and Signature: I certify under penalty of perjury that this patient has a serious health condition and requires a care provider.
I have performed a physical examination and/or treated the patient. I am authorized to certify a patient disability or serious health condition pursuant to California
Unemployment Insurance Code Section 2708.
Under sections 2116 and 2122 of the California Unemployment Insurance Code, it is a violation for any individual who, with intent to defraud, falsely certifies the
medical condition of any person in order to obtain disability insurance benefits, whether for the maker or for any other person, and is punishable by imprisonment and/or
a fine not exceeding $20,000. Sections 1143 and 3305 require additional administrative penalties.
Original Signature of Attending Physician/Practitioner –
RUBBER STAMP IS NOT ACCEPTABLE
D20. SPECIALTY (IF ANY)
D16. STATE OR COUNTRY PHYSICIAN/PRACTITIONER IS LICENSED.
D6. DIAGNOSIS OR, IF NOT YET DETERMINED, A DETAILED STATEMENT OF SYMPTOMS
NO
YES
D18. PHYSICIAN/PRACTITIONER’S ADDRESS (POST OFFICE BOX IS NOT ACCEPTABLE AS THE SOLE ADDRESS)
CITY STATE/PROV. ZIP OR POSTAL CODE COUNTRY (IF NOT U.S.A.)
PHYSICIAN/PRACTITIONER’S PHONE NO.
Date Signed ( M M | D D | Y Y Y Y)
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SAMPLE, this page for reference only
PART E – MILITARY ASSIST CERTIFICATION (TO BE COMPLETED BY THE CLAIMANT)
E1. YOUR SOCIAL SECURITY
NUMBER
E2. YOUR LEGAL NAME (FIRST / MIDDLE INITIAL / LAST)
E6. MILITARY MEMBER’S MAILING ADDRESS
CITY STATE/PROV. ZIP
OR POSTAL CODE COUNTRY (IF NOT U.S.A.)
E3. NAME OF MILITARY MEMBER ON COVERED ACTIVE DUTY OR IMPENDING CALL TO COVERED ACTIVE DUTY STATUS (FIRST / MIDDLE INITIAL / LAST)
E4. MILITARY MEMBER’S
DATE OF BIRTH
M M D D Y Y Y Y
E5. MILITARY MEMBER’S
GENDER
o
MALE
o
FEMALE
E7. LAST FOUR DIGITS OF MILITARY MEMBER’S SOCIAL SECURITY NUMBER
E8. PERIOD OF MILITARY MEMBER’S COVERED ACTIVE DUTY
M M D D Y Y Y Y M M D D Y Y Y Y
TO
E9. DATE MILITARY MEMBER
WAS NOTIFIED OF COVERED
ACTIVE DUTY
M M D D Y Y Y Y
E10. PLEASE SELECT ONE OF THE FOLLOWING AND ATTACH THE INDICATED DOCUMENT TO SUPPORT THAT THE MILITARY MEMBER IS ON COVERED ACTIVE DUTY OR
IMPENDING CALL OR ORDER TO COVERED ACTIVE DUTY STATUS
o
COVERED ACTIVE DUTY ORDERS
o
LETTER OF IMPENDING CALL OR ORDER TO COVERED DUTY
o
DOCUMENTATION OF MILITARY LEAVE SIGNED BY THE APPROVING AUTHORITY FOR MILITARY MEMBER’S REST AND RECUPERATION
E11. THE QUALIFYING EVENT FOR THE PFL CLAIM IS TO: (One or more reasons may be selected)
o
PROVIDE/ARRANGE CHILDCARE FOR MILITARY MEMBER’S CHILD
o
PROVIDE/ARRANGE CARE FOR MILITARY MEMBER’S PARENT
o
ATTEND COUNSELING
o
MAKE FINANCIAL/LEGAL ARRANGEMENTS
o
ASSIST MILITARY MEMBER DURING REST AND RECUPERATION LEAVE
o
ATTEND MILITARY EVENT
o
REPRESENT MILITARY MEMBER AT FEDERAL, STATE, OR LOCAL AGENCIES
o
ADDRESS ISSUES DUE TO MILITARY MEMBER’S DEATH
o
OTHER:
E12. WRITTEN DOCUMENTION SUPPORTING THIS REQUEST FOR LEAVE IS AVAILABLE AND ATTACHED?
o
YES
o
NO
o
NONE AVAILABLE
NOTE: A complete and sufficient certification to support a request for PFL leave due to a qualifying event includes any available written documentation that supports the
need for leave. Documentation may include; a copy of a meeting announcement for informational briefings sponsored by the military, a document confirming the military
member’s Rest and Recuperation leave, an appointment with a third party (i.e., a counselor, school official, or staff at a care facility), or a copy of a bill for services for the
handling of legal or financial affairs. If leave is requested to meet with a third party, the employee must provide the supporting documentation of the meeting that includes
the name, address, and appropriate contact information of the individual or entity with whom you are meeting (i.e., either phone number, fax number, or email address of
the individual or entity).
E13. Declaration and Signature. By my signature on this military assist certification, 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 perjury 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 the claim, whichever is later.
Original Signature of Military Assist Claimant (DO NOT PRINT) Date Signed ( M M | D D | Y Y Y Y)
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SAMPLE, this page for reference only
QUALIFYING EVENT FOR LEAVE - DOCUMENTATION
If leave is requested to meet with a third party, the employee must provide supporting documentation of the meeting that includes the name, address, and appropriate contact
information of the individual or entity with whom you are meeting (i.e., either the phone number, fax number or email address of the individual or entity). The reason for a meeting
can include: arranging for child or parental care, counseling, making financial or legal arrangements, acting as the military member’s representative before a federal, state or local
agency for purposes of obtaining, arranging or appealing military service benefits, or attending any event sponsored by the military or military service organizations.
NAME OF INDIVIDUAL WITH WHOM CLAIMANT IS MEETING:____________________________________________
TITLE:______________________________________
ORGANIZATION:___________________________________________
PHONE NUMBER (provide area or country code):____________________________________
FAX NUMBER (provide area or country code):_______________________________
EMAIL ADDRESS:_____________________________________________________
MAILING ADDRESS
Mailing Address
City State/Prov ZIP or Postal Code Country (if not U.S.A.)
DESCRIBE NATURE OF MEETING. INCLUDE DATES, IF KNOWN:
PLEASE SUBMIT SUPPORTING DOCUMENTATION, IF APPLICABLE
(Attach an additional sheet if more space is required)
YOUR SOCIAL SECURITY NUMBER YOUR LEGAL NAME (FIRST / MIDDLE INITIAL / LAST)
DE 2501F Rev. 5 (12-20) (INTERNET)
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