EDD Form

Select your zip code

Contact Information

First

Middle

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

Email Address

Date Applied for Claims

What did you apply for?

What is your issue?

Have you certified for ALL weeks pending of benefits?

Yes

Unsure

If no, which weeks have you certified for?

How many weeks of benefits are you owed? (Please answer as accurately as possible)

When was the last time you received a correspondence from EDD (via mail, phone, or text)

Have you contacted another elected official?

Yes

Who have you contacted?

Summary of Issue

REQUEST FOR ASSISTANCE AND AUTHORIZATION FOR RELEASE OF INFORMATION

Please carefully read the following:

By completing this form, I am requesting the Office of Majority Leader Reyes (the “Majority Leader”) to assist me in working with the Employment Development Department (EDD) on my claim. I acknowledge that this may require the release of information contained in my records the dissemination of which may be prohibited by law. Therefore, I hereby authorize EDD and the Majority Leader to share all relevant portions of my records with each other, and to discuss matters relating to those records and my claim, until my claim is resolved.

I agree that I will not submit any personal identifiable information through this form that is not specifically requested. If the Majority Leader’s office needs additional information, such as my EDD number, the office will contact me to request that information.

By clicking here, I accept and agree to the terms in this form.

Zip code entered is outside of the District. Please use the Find Your Rep webpage to find your District Representatives.