Edd Form De 2523F PDF Details

The Edd De 2523F form serves a critical role within the framework of Voluntary Plan Family Leave (VPFL) claims, tailored to accommodate those dedicating time to provide care under the auspices of a voluntary plan. Designed meticulously to gather essential claimant information, this document bridges the procedural gap between claimants and their entitlement to paid family leave benefits. It emphasizes the need to provide comprehensive details, ranging from personal information like social security numbers and addresses to specifics about the family care or child bonding scenario prompting the claim. Concurrently, it sets forth directives for submitting the form—within a stipulated timeframe of 15 days following the commencement of the first claim, with subsequent information to be provided after the final payment. This dual-phase submission process, underscored by a meticulous delineation of required data points, underscores the form's pivotal role in ensuring claimants' access to benefits while also stipulating clear guidelines for adherence. Additionally, the form accommodates various scenarios, including adjustments and re-established claims, further emphasizing its versatility and critical function in administering VPFL benefits accurately and efficiently.

QuestionAnswer
Form NameEdd Form De 2523F
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesissuance, SDI, CALIFORNIA, CU

Form Preview Example

REPORT OF VOLUNTARY PLAN FAMILY LEAVE (VPFL) CLAIM

PLEASE READ INSTRUCTIONS BEFORE COMPLETING THIS FORM

CLAIMANT INFORMATION (FAMILY MEMBER PROVIDING CARE)

COMPLETE ITEMS 1 – 13 AND 23 – 25. SUBMIT WITHIN 15 DAYS AFTER RECEIPT OF A FIRST CLAIM FOR PAID FAMILY LEAVE BENEFITS.

1. SOCIAL SECURITY NUMBER

2. CLAIMANTS NAME (FIRST, MIDDLE, LAST)

3. CLAIM EFFECTIVE DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

CLAIMANTS MAILING ADDRESS

 

 

 

5.

SEX

 

 

 

 

 

 

STREET/PO BOX

 

 

 

 

 

 

 

 

MALE

 

FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

STATE

ZIP CODE

6.

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

VOLUNTARY PLAN NUMBER

8. VOLUNTARY PLAN EMPLOYER NAME

 

 

 

 

 

 

 

 

 

 

9.TYPE OF VPFL CLAIM (CHECK ONE):

CLAIM INFORMATION

FAMILY CARE CLAIM

CHILD BONDING CLAIM

IS THIS BONDING CLAIM RELATED TO AN SDI OR VP PREGNANCY CLAIM?

YES

UNKNOWN

10.FAMILY CARE/BONDING RECIPIENT’S NAME:

11. FAMILY CARE/BONDING RECIPIENT’S DATE OF BIRTH: / /

12. IF THE BONDING RECIPIENT IS A FOSTER OR ADOPTED CHILD, DATE OF PLACEMENT WITH THE CLAIMANT: / /

13.DO YOU WANT STATE AWARD INFORMATION?

NO

YES (IF “YES”, YOU MUST COMPLETE THE ADDRESS AREA AT THE BOTTOM OF THIS PAGE.)

FOR DEPARTMENT USE ONLY

CLAIM EFFECTIVE DATE

WEEKLY BENEFIT AMOUNT

$

MAXIMUM BENEFIT AMOUNT

$

COMPLETE ITEMS 14 25 AND SUBMIT WITHIN 35 DAYS AFTER FINAL PAYMENT FOR EACH FAMILY LEAVE PERIOD.

14. VPFL WEEKLY BENEFIT AMOUNT

15.

NUMBER OF WAITING PERIOD

16. FIRST DAY PAID

17. LAST DAY PAID

 

 

DAYS ASSESSED

 

 

 

 

 

 

 

18. NUMBER OF DAYS BENEFITS

19.

WERE ONE OR MORE DAYS

20. TOTAL AMOUNT OF BENEFITS

21. TOTAL AMOUNT DIVERTED TO

PAID

 

PAID AT LESS THAN THE FULL

PAID

SATISFY SUPPORT OBLIGATION

 

 

DAILY RATE?

 

 

 

 

 

$

$

22.CLAIM STATUS (CHECK ALL APPROPRIATE)

BENEFITS EXHAUSTED

CLAIMANT RETURNED TO WORK

BENEFITS DENIED (ATTACH DENIAL LETTER)

RE-ESTABLISHED CLAIM

ADJUSTMENT

23.(REQUIRED) TYPE OR PRINT NAME OF PERSON COMPLETING THIS FORM

24.TELEPHONE NUMBER

( )

25.DATE

SUBMIT COMPLETED FORM AS FOLLOWS:

PRINT AND MAIL TO THE PFL OFFICE, P.O. BOX 997017, SACRAMENTO, CALIFORNIA 95799-7017

IN THE AREA BELOW, ENTER THE NAME AND ADDRESS (INCLUDING ZIP CODE) OF THE EMPLOYER OR PLAN ADMINISTRATOR IF REQUESTING STATE AWARD INFORMATION.

DE 2523F Rev. 3 (1-13) (INTERNET)

Page 1 of 2

CU

INSTRUCTIONS FOR COMPLETING THE

REPORT OF VOLUNTARY PLAN FAMILY LEAVE CLAIM, DE 2523F

Complete items 1-13 and 23-25, and return within 15 days after receipt of a first claim for VPFL benefits. (California Code of Regulations, title 22, section 3267-1). Any missing information may result in returning the form and delaying the award information.

Items 1-13, Information regarding the family care/child bonding provider and his/her family member.

1.Enter all digits of VPFL claimant’s social security number (SSN). (A claim cannot be processed without an accurate SSN. The use of an incorrect SSN can result in erroneous notices to the claimant and employer.)

2.Enter the VPFL claimant’s full name.

3.Enter the date the VPFL claim began. This is the date the claimant has given as the first date he/she wants benefits to begin.

4.Enter the VPFL claimant’s current mailing address.

5.Enter a check mark in the appropriate box.

6.Enter the month, day, and year of the VPFL claimant’s date of birth.

7.Enter the six digit voluntary plan number.

8.Enter the voluntary plan employer's name.

9.Enter an “X” in the appropriate box for family care or child bonding. If the VP previously paid benefits on a disability pregnancy claim, and the claimant is now requesting child-bonding benefits for the same child, check the “Yes” box. If unsure of the type of claim previously paid, mark the “Unknown” box.

10.Enter the name of the care recipient (family member) who will receive family care or the name of the child with whom the claimant will bond.

11.Enter the birth date of the care recipient (family member) or the child with whom the claimant will bond.

12.Enter the date that the foster or adopted child was placed in the claimant’s home.

13.Enter an “X” in the appropriate box. If “Yes” is checked, enter the employer or plan administrator name and address at the bottom of the first page, and the Department will mail the award information to the address provided.

Items 14-25, Information regarding benefits. Complete and return within 35 days after final payment for each period of Voluntary Plan Family Leave (California Code of Regulations, title 22, section 3267-1).

14.Enter the Voluntary Plan weekly benefit amount.

15.Enter the number of non-payable waiting period days assessed prior to issuance of the first benefit check. If no waiting period was assessed, enter a “0”.

16.Enter the first date for which benefits were paid.

17.Enter the last date for which benefits were paid.

18.Enter the number of days for which benefits were paid.

19.Enter “yes” if the claimant was paid less than his/her full daily benefit rate for one or more days. Enter “no” if the claimant did not receive less than his/her full daily benefit rate for any days which benefits were paid.

20.Enter the total dollar amount of benefits paid.

21.Enter the amount of PFL benefits that were diverted to satisfy a support obligation. (Enter the amount of benefits withheld under the Support Intercept Program.) This amount must be included in the total of item 19.

22.Enter an “X” in the boxes that apply to the current claim status.

Benefits Exhausted: The total maximum benefit amount was paid on the claim.

PFL claimant has returned to work: Self-explanatory

Benefits Denied: No benefits have been paid. Include with this form a copy of the claimant’s denial letter. You are required to notify the claimant in writing if you deny benefits in whole or in part. A copy of that letter must be sent to the Department with the DE 2523F.

Re-established claim: This applies if there has been a break in benefit payment periods for the same or different care recipient or child-bonding claim within the past 12 months.

Adjustment: Use if a previous report was submitted, and this is a correction or change to that report.

23.Enter the printed name of the person completing the form.

24.Enter the telephone number of the person completing the form.

25.Enter the current date.

MAIL COMPLETED FORM TO:

EDD-Paid Family Leave (PFL)

P.O. Box 997017

Sacramento, CA 95799-7017

DE 2523F Rev. 3 (1-13) (INTERNET)

Page 2 of 2

How to Edit Edd Form De 2523F Online for Free

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This PDF form will need some specific information; to ensure accuracy and reliability, please make sure to take note of the suggestions below:

1. It is important to fill out the PFL properly, thus be attentive while filling in the sections comprising all these fields:

Completing section 1 in CALIFORNIA

2. Right after this part is completed, proceed to type in the applicable details in all these: COMPLETE ITEMS AND SUBMIT, NUMBER OF WAITING PERIOD, FIRST DAY PAID, DAYS ASSESSED, NUMBER OF DAYS BENEFITS, WERE ONE OR MORE DAYS, TOTAL AMOUNT OF BENEFITS, LAST DAY PAID TOTAL AMOUNT, PAID, PAID AT LESS THAN THE FULL DAILY, PAID, SATISFY SUPPORT OBLIGATION, CLAIM STATUS CHECK ALL APPROPRIATE, BENEFITS EXHAUSTED, and CLAIMANT RETURNED TO WORK.

CALIFORNIA writing process shown (portion 2)

When it comes to CLAIMANT RETURNED TO WORK and PAID AT LESS THAN THE FULL DAILY, make sure you take a second look here. These two are the most important ones in the page.

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