De 2501F Form – Fill Out and Use This PDF

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.

EDD Debit Card Fee Disclosures

*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.

Spend Money

*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.

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:

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.

SAMPLE, this page for reference only

Claim for Paid Family Leave (PFL) Benefits

PART A – STATEMENT OF CLAIMANT (CARE, BONDING, or MILITARY ASSIST PROVIDER)

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)

A17. LEGAL NAME OF CARE, BONDING, OR MILITARY ASSIST RECIPIENT (FIRST / MIDDLE INITIAL / LAST)

X

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.

SAMPLE, this page for reference only

PART B – BONDING CERTIFICATION (TO BE COMPLETED BY PERSON CLAIMING PFL BENEFITS TO BOND WITH A CHILD)

B8. LEGAL NAME OF CHILD (FIRST MIDDLE INITIAL LAST)

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.

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.

C7. Authorized Representative signing on behalf of care recipient must complete the following: I,______________________________________ , represent the care or bonding recipient

SAMPLE, this page for reference only

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.)

D5. PATIENT’S NAME (FIRST MIDDLE INITIAL LAST)

D6. DIAGNOSIS OR, IF NOT YET DETERMINED, A DETAILED STATEMENT OF SYMPTOMS

D13. APPROXIMATELY HOW MANY TOTAL HOURS PER DAY WILL PATIENT REQUIRE CLAIMANT?

HOURS COMMENTS

D17. PHYSICIAN/PRACTITIONER’S NAME (FIRST MIDDLE INITIAL LAST)

D18. PHYSICIAN/PRACTITIONER’S ADDRESS (POST OFFICE BOX IS NOT ACCEPTABLE AS THE SOLE ADDRESS)

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.

SAMPLE, this page for reference only

PART E – MILITARY ASSIST CERTIFICATION (TO BE COMPLETED BY THE CLAIMANT)

E3. NAME OF MILITARY MEMBER ON COVERED ACTIVE DUTY OR IMPENDING CALL TO COVERED ACTIVE DUTY STATUS (FIRST / MIDDLE INITIAL / LAST)

E6. MILITARY MEMBER’S MAILING ADDRESS

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

oCOVERED ACTIVE DUTY ORDERSoLETTER OF IMPENDING CALL OR ORDER TO COVERED DUTY

oDOCUMENTATION 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)

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.

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.

PLEASE SUBMIT SUPPORTING DOCUMENTATION, IF APPLICABLE

(Attach an additional sheet if more space is required)

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

DESCRIBE NATURE OF MEETING. INCLUDE DATES, IF KNOWN: