Fillable Printable Claim For Paid Family Leave (Pfl) Benefits (De 2501F)
Fillable Printable Claim For Paid Family Leave (Pfl) Benefits (De 2501F)
Claim For Paid Family Leave (Pfl) Benefits (De 2501F)
Claim for Paid Family Leave
(PFL) Benefits
PART
A
–
STATEMENT
OF
CLAIMANT
(
CARE
OR
BONDING
PROVIDER
)
A1.YOUR SOCIAL SECURITY NO.
A2.YOUR DATE OF BIRTH
MMDDYYYY
A3.
LANGUAGE YOU PREFER TOUSE
ENGLISHESPAÑOLOTHER (PRINT BELOW)
A4.
YOUR LEGAL NAME
FIRST NAMEMILAST NAME
A5.
YOUR GENDER
MALE FEMALE
A6.
YOUR TELEPHONE NUMBER
A7.
OTHER LAST NAMES, IF ANY, UNDER WHICH YOU HAVE WORKED
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)
CITYSTATE/PROV.ZIP OR POSTAL CODECOUNTRY (IF NOT U.S.A.)
A9.
NAME OF YOUR EMPLOYER
MAILING ADDRESS
CITYSTATE/PROV.ZIP OR POSTAL CODEEMPLOYER’S TELEPHONE NUMBER
A10.
DATE YOU LAST WORKED
MMDDYYYY
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
A14.
WHY DID YOU
OR WILL YOU REDUCE YOUR WORK HOURS OR STOP WORKING?
CARE FOR BOND WITH
FAMILY MEMBER CHILD OTHER
(EXPLAIN)
A15.
WHAT IS YOUR OCCUPATION?
A16.
LEGAL NAME OF PERSON FOR WHOM YOU ARE CARING (FIRSTMIDDLE INITIALLAST) OR WITH WHOM YOU ARE BONDING (CARE OR BONDING RECIPIENT)
A18.
IS ANY OTHER FAMILY MEMBER READY, WILLING, AND ABLE AND
AVAILABLE TO PROVIDE CARE FOR THE SAME PERIOD YOU ARE
NO YESCLAIMING PFL BENEFITS?
A19.
HAVE YOU CLAIMED OR DO YOU PLAN TO CLAIM WORKERS’ COMPENSATION
BENEFITS FOR ANY PORTION OF THE PERIOD COVERED BY THIS CLAIM?
NO YES
A20.
DO YOU HAVE MORE
THAN ONE EMPLOYER?
NO YES
A21.
IF YOUR EMPLOYER(S) CONTINUED OR WILL CONTINUE TO PAY YOU
DURING YOUR FAMILY LEAVE, INDICATE TYPE OF PAY:
SICK VACATION OTHER (EXPLAIN)
A22.
MAY WE DISCLOSE BENEFIT PAYMENT
INFORMATION TO YOUR EMPLOYER(
S)?
NO YES
A23.
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?.........................................................................................................................................
NOYES
A24.
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 or
bonding with the care recipient named above; (2) authorize EDD to release my personal information as shown on this claim to the care recipient and 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 to 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.
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 Address2
nd
Witness Signature and Address
DE 2501F Rev. 2 (10-16)(INTERNET)
Page 1 of 4
DO NOT DETACH PAGES - NO SEPARE LAS PAGINAS
2501F10161
A17.THEABOVE-NAMEDCAREORBONDINGRECIPIENTISYOUR:
REGISTERED DOMESTIC PARENT GRAND GRAND
CHILD SPOUSE PARTNE
R
PARENT IN-LAW PARENT CHILD SIBLING OTHER
(
EXPLAIN
)
CU
SAMPLE
CARE RECIPIENT’S AUTHORIZATION FOR DISCLOSURE OF
PERSONAL-HEALTH INFORMATION
I authorize my physician or practitioner, as identified on Part D of this claim, to disclose
my current personal-health information to my care provider, as identified on Part A of
this claim, and to the California Employment Development Department (EDD).
I understand that such information includes a diagnosis and prognosis of my current
condition, the date it commenced, and an estimation of the amount of care that I require
from my care provider as a result of my current condition. I further understand that
disclosure of my personal-health information may include my AIDS/HIV status, drug or
alcohol addiction, or any other physical or mental condition.
I understand that EDD may disclose this information as authorized by the California
Unemployment Insurance Code and that such re-disclosed information may no longer
be protected. I agree that photocopies of the authorization form in conjunction with
my signature on Page 3 in Item 6 of Part C shall be as valid as the original.
I make this authorization to support my care provider’s claim for Paid Family Leave
benefits. I understand that I may not revoke my authorization to avoid prosecution or
to prevent EDD’s recovery of monies to which it is legally entitled.
WE CANNOT PROCESS THIS CLAIM UNLESS YOU SIGN BOTH THIS PAGE AND PAGE 3
IN ITEM C6 OF PART C.
Care recipient’s name (Print your name)
Date signedCare recipient’s signature (Sign your name)
DE 2501F Rev. 2 (10-16)(INTERNET)Page 2 of 4
I understand that unless I inform EDD in writing at P.O. Box 989315, West Sacramento,
CA 95798-9315, that I wish to revoke this authorization, it will be valid for 10 years
from the date EDD receives it or the effective date ofthis claim, whichever is later. I
understand that I have the right to receive acopy of an authorization form from EDD if I
request one in writing.
SAMPLE
PART B – BONDING CERTIFICATION(TO BE COMPLETED BY PERSON CLAIMING PFL BENEFITS TO BOND WITH A CHILD)
B1.
YOUR SOCIAL
SECURITY NUMBER
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
B4.
YOUR LEGAL LAST NAME (NEEDED IN CASE PAGES OF THIS
CLAIM BECOME SEPARATED
)
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 (FIRSTMIDDLE INITIALLAST)
B9.
CHILD’S RESIDENCE ADDRESS (
IF DIFFERENT FROM CLAIMANT’S)
CITYSTATE/PROV.ZIP OR POSTAL CODECOUNTRY (IF NOT U.S.A.)
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
DECLARATION OF PATERNITY, CS-909
INDEPENDENT ADOPTION PLACEMENT AGREEME
NT, AD-924
FOSTER CARE PLACEMENT RECORD, SOC-815
OTHER
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.
Date Signed ( M M | D D | Y Y Y Y)Original Signature of Bonding Claimant– RUBBER STAMP IS NOT ACCEPTABLE
PART C – STATEMENT OF
CARE RECIPIENT
(MAY BE COMPLETED BY CLAIMANT IF CARE RECIPIENT IS MENTALLY OR PHYSICALLY UNABLE TO DO SO.
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
C4.
LEGAL NAME OF CARE RECIPIENT (
FIRSTMIDDLE INITIALLAST)
C5.
CARE RECIPIENT’S RESIDENCE ADDRESS
CITYSTATE/PROV.ZIP OR POSTAL CODECOUNTRY (IF NOT U.S.A.)
C6.
CONFIRMATION OF MEDICAL DISCLOSURE AUTHORIZATION.I have read and signed
the Care Recipient’s Authorization for Disclosure of Personal-Health Information on page 2 of
this claim. I understand that by signing it I have agreed to all its provisions and terms. I further
understand that copies of my signature below are as valid as the original.
Care Recipient’s Signature (DO NOT PRINT)Date Signed ( M M | D D | Y Y Y Y)
C7.
Authorized Representativesigning on behalf of care recipient must complete the following: I,______________________________________ , represent the care or bonding recipient
in this matter as authorized by
parental rightpower of attorney (attach copy)court order (attach copy) (For spouse or domestic partner, contact EDD.)
Authorized Representative’s Signature (DO NOT PRINT)Date Signed (M M | D D | Y Y Y Y)
DE 2501F Rev. 2 (10-16)(INTERNET)
Page 3 of 4
ADOPTIVE PLACEMENT AGREEMENT, AD-907
2501F10162
SAMPLE
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.
PARTD–PHYSICIAN/PRACTITIONER'SCERTIFICATION(DONOTCOMPLETETHISPARTIFYOU AREBONDINGWITHACHILD.)
D1.
PFL CLAIMANT’S (CARE
PROVIDER’S) SOCIAL
SECURITY NUMBER
D2.
PFL CLAIMANT’S NAME (FIRSTMIDDLE INITIALLAST)
D3.
PATIENT’S
DA
TE
OFBIRTH
M M D D Y Y Y Y
D
4.
DOES Y
OUR
PATIENT
R
EQUIRE C
ARE
B
Y
THE CLAIMANT
?
NO (SKIP TO D15) YES
D5.
PATIENT’S NAME (FIRSTMIDDLE INITIALLAST)
D6.
DIAGNOSIS OR, IF NOT YET DETERMINED, A DETAILED STATEMENT OF SYMPTOMS
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
REQUIRECAREBYTHECLAIMANT
M M D D Y Y Y Y PERMANENT
D
1
3
.
APPROXIMATELY
H
OW M
ANY
TOTAL H
OUR
S PER
DA
Y
W
I
LL PATIENT
R
EQUIRE CLAIMANT
?
HOURS
COMMENTS
D14.
WOULD DISCLOSURE OF THIS CERTIFICATE TO YOUR PATIENT BE MEDICALLY OR PSYCHOLOGICALLY DETRIMENTAL?...........................
NOYES
D
1
5
.
PHYSICIAN/PRACTITIONER'S
L
ICENSE N
UMBER
D
1
6
.
STAT
E OR
COUNTRY
PHYSICIAN/PRACTITIONER
IS LICENSED
.
D17.
PHYSICIAN/PRACTITIONER'S NAME
(
FIRST
MIDDLE INITIALLAST)
D18.
PHYSICIAN/PRACTITIONER'S ADDRESS
(
POST
OFFICEBOXISNOTACCEPTABLEASTHESOLEADDRESS)
CITYSTATE/PROV.ZIP OR POSTAL CODECOUNTRY (IF NOT U.S.A.)
D19.
TYPE OF PHYSICIAN/PRACTITIONER
D20.
SPECIALTY(IF ANY)
PHYSICIAN/PRACTITIONER’SPHONENO.
Date Signed (
M M | D D | Y Y Y Y)
OriginalSignatureofAttendingPhysician/Practitioner –RUBBER STAMPIS NOTACCEPTABLE
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.
DE 2501F Rev. 2 (10-16)(INTERNET)
Page 4 of 4
D7.
PRIMARY
ICD
CODE
D8.
SECONDARY
ICD
CODES
D9.
DATEPATIENT’SCONDITIONCOMMENCED
M M D D Y Y Y Y
2501F10163
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.
INSTRUCTIONS F
OR COMPLETING THIS FORM:
PleasecompletetheinformationinthespacesprovidedinUPPERCASEusingblackink.Donotusespecialcharacters(-,./').
Ifhandwritten,print each letter or number in a separate box. Ignore the boxes provided if using a typewriter or printer.
SAMPLE
