2501F FORM PDF

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. Get the de f form. Description of form de f. Claim for Paid Family Leave PFL Benefits F PART A STATEMENT OF CLAIMANT CARE OR. Fill De f Form Download, download blank or editable online. Sign, fax and printable from PC, iPad, tablet or mobile with PDFfiller ✓ Instantly ✓ No software.

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All other claimants filing for bonding or care claims: Be sure to write clearly in the spaces provided, use black ink only, and sign the form.

If you have not received this form within 10 days after your disability claim ends, please call New mothers transitioning from a Disability Insurance DI -related pregnancy claim to bonding: Box West Sacramento, CA Authorization and Statement of Care: The EDD is unable to guarantee the accuracy of this translation and is therefore not liable for any inaccurate information or changes fofm the formatting of the firm resulting from the translation application tool.

Make sure to put a stamp on the envelope.

Provide the information below ONLY if it applies to you: Any wages you received or expect to receive from your employer sick leave, paid-time-off [PTO], vacation pay, annual leave, and wages earned after you stopped working. Deaf, speech impaired, and hard of hearing callers can contact PFL directly by Teletypewriter TTY this number does not accept voice calls.

Do not submit duplicates of the same claim. If you are a woman currently receiving Disability Insurance pregnancy-related benefits, it is not necessary to request a Claim for Paid Family Leave Benefits. Follow the steps below to properly submit a PFL claim by mail. Complete all sections of the DE FP and submit no later than 41 days from the date you wish to begin your bonding claim.

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For bonding, parts A, B, and supporting documents. Last date you worked your regular duties and hours or date you began working at modified duty or less than full duty.

Inquiries about individual claims using this form will not be answered. Some forms and publications are translated by the department in other languages. For those forms, visit the Online Forms and Publications section.

When calling via the California Relay Serviceplease provide the Paid Family Leave number to the operator. Any discrepancies or differences created in the translation are not binding and have no legal effect for compliance or enforcement purposes. For faster processing, use SDI Online to file your claim. California Driver License number.

To request general program information or data about State Disability Insurance, complete the State Disability Insurance Request for Information Firm DE E and return it to the Employment Development Department using the appropriate email address listed on the form. To submit by US mail you must first order a claim form. A properly completed application will include: All are available free of charge, corm you download or order for delivery by mail.

A form will be mailed to you.

How to File a Paid Family Leave (PFL) Claim in SDI Online

If any questions arise related to the information contained in fomr translated website, please refer to the English version. Visit an SDI Office. Mothers without a pregnancy DI claim, new fathers, and foster or adoptive parents will need to provide a Proof of Relationship document with your bonding claim.

Please note that your employer will be notified that you have submitted a PFL claim. You may need to download the free Adobe Reader to view and print linked documents. First and last name.

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To submit the claim, mail the completed paper 25001f form to the EDD in the pre-addressed envelope to:. The web pages currently in English on the EDD website are the official and accurate source fform the program information and services the EDD provides.

For those forms, visit the Online Forms and Publications section. This will delay claim processing. Visit Online Forms and Publications and order a form online.

Paid Family Leave – Forms and Publications

You may mail it with your paper form or scan and upload it to your computer to submit with your claim using SDI Online. No additional documentation is required. The EDD is unable to guarantee the accuracy of this translation and is therefore not liable for any inaccurate information or changes in the formatting of the pages resulting from the translation application tool.

New mothers transitioning from a DI-related pregnancy claim to bonding: The web pages currently in English on the EDD website are the official and accurate source for the program information and services the EDD provides.

How to File a Paid Family Leave (PFL) Claim in SDI Online

PFL law requires employers to provide the Paid Family Leave – Forrm brochure only to new employees and employees who request leave to care for a seriously ill family member or bond with a new child. However, your medical information is confidential and will not be shared with your employer. These brochures may be downloaded and provided as official notices to employees.

Some forms and publications are translated by the department in other languages. To order an original form, visit Online Forms and Publicationsor call Forms and Publications Labor Market Information.

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