Fillable Printable Report Of Voluntary Plan Family Leave (Vpfl) Claim (De 2523F)
Fillable Printable Report Of Voluntary Plan Family Leave (Vpfl) Claim (De 2523F)
Report Of Voluntary Plan Family Leave (Vpfl) Claim (De 2523F)
DE 2523F Rev. 4 (8-17) (INTERNET) Page 1 of 3 CU
REPORT OF VOLUNTARY PLAN FAMILY LEAVE (VPFL) CLAIM
PLEASE READ INSTRUCTIONS BEFORE COMPLETING THIS FORM
A. CLAIMANT INFORMATION (FAMILY MEMBER PROVIDING CARE)
COMPLETE SECTION A, ITEMS 1 – 17 AND SUBMIT WITHIN 15 DAYS AFTER RECEIPT OF A FIRST CLAIM FOR PAID FAMILY LEAVE
BENEFITS. (RETAIN A COPY OF COMPLETED SECTION A)
1.
SOCIAL SECURITY NUMBER
– –
2.
CLAIMANT
’
S NAME
(
FIRST
,
MIDDLE
,
LAST
)
3.
CLAIM EFFECTIVE DATE
4.
CLAIMANT
’
S MAILING ADDRESS
5.
SEX
MALE FEMALE
6.
DATE OF BIRTH
MM DD YYYY
7.
VOLUNTARY
PLAN NUMBER
–
8.
VOLUNTARY PLAN EMPLOYER NAME
9.
CLAIMANT
’
S PHONE
CLAIM INFORMATION
10. TYPE OF VPFL CLAIM (CHECK ONE): FAMILY CARE CLAIM CHILD BONDING
IS THIS BONDING CLAIM RELATED TO AN SDI OR VP PREGNANCY CLAIM? YES UNKNOWN
11. FAMILY CARE/BONDING RECIPIENT’S NAME (REQUIRED):
12. FAMILY CARE/BONDING RECIPIENT’S DATE OF BIRTH (REQUIRED):
13
.
IF THE BONDING RECIPIENT IS A FOSTER OR ADOPTED CHILD, DATE OF PLACEMENT WITH THE CLAIMANT:
14. DO YOU WANT STATE AWARD INFORMATION? NO YES
IF “YES,” ENTER THE NAME AND ADDRESS (INCLUDING ZIP CODE) OF EMPLOYER OR PLAN ADMINISTRATOR.
Name:
Address:
15. (
REQUIRED
)
TYPE
/
PRINT NAME OF PERSON COMPLETING SECTION A
16.
TELEPHONE NUMBER
17.
DATE
FOR DEPARTMENT USE ONLY
CLAIM EFFECTIVE DATE
WEEKLY BENEFIT AMOUNT
$
MAXIMUM BENEFIT AMOUNT
$
B. WITHIN 35 DAYS AFTER FINAL PAYMENT FOR EACH FAMILY LEAVE PERIOD (ON RETAINED COPY), COMPLETE
SECTION 6, ITEMS 18 – 28 AND SUBMIT.
18.
VPFL WEEKLY BENEFIT AMOUNT
$
19.
FIRST DAY PAID
20.
LAST DAY PAID
21.
NUMBER OF DAYS
BENEFITS PAID
22.
WERE ONE OR MORE DAYS PAID AT
LESS THAN THE FULL DAILY RATE?
23.
TOTAL AMOUNT OF BENEFITS PAID
$
24.
TOTAL AMOUNT DIVERTED TO
SATISFY SUPPORT OBLIGATION
$
25.
CLAIM STATUS
(
CHECK ALL APPROPRIATE
)
BENEFITS EXHAUSTED CLAIMANT RETURNED TO WORK BENEFITS DENIED (ATTACH DENIAL LETTER)
RE-ESTABLISHED CLAIM ADJUSTMENT
26.
(
REQUIRED
)
TYPE OR PRINT NAME OF PERSON COMPLETING SECTION B
27.
TELEPHONE NUMBER
28.
DATE
CITY
STREET
/
PO BOX
S
TATE
ZIP CODE
/
/
/
/
/
/
DE 2523F Rev. 4 (8-17) (INTERNET) Page 2 of 3
I
NSTRUCTIONS FOR COMPLETING THE
REPORT OF VOLUNTARY PLAN FAMILY LEAVE CLAIM, DE 2523F
Any missing information may result in returning the form and delaying the award information.
Section A: Complete items 1-17 and return within 15 days after receipt of a first claim for VPFL benefits. (California Code of
Regulations, title 22, section 3267-1).
Submit to address below. Retain copy of completed Section A.
Items 1-14, 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 claim effective 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 the claimant’s telephone number.
10. 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.
11. 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.
12. Enter the birth date of the care recipient (family member) or the child with whom the claimant will bond.
13. Enter the date that the foster or adopted child was placed in the claimant’s home.
14. Enter an “X” in the appropriate box. If “Yes” is checked, enter the employer or plan administrator name and address in the box
below. The Department will mail the award information to the address provided.
15. Enter the printed name of the person completing Section A.
16. Enter the telephone number of the person completing Section A.
17. Enter the current date.
Section B: Information regarding benefits. On retained copy of completed Section A, complete Items 18 – 28 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).
18. Enter the Voluntary Plan weekly benefit amount.
19. Enter the first date for which benefits were paid.
20. Enter the last date for which benefits were paid.
21. Enter the number of days for which benefits were paid.
22. 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.
23. Enter the total dollar amount of benefits paid.
24. 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 23.
25. 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
DE 2523F Rev. 4 (8-17) (INTERNET) Page 3 of 3
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.
26. Enter the printed name of the person completing Section B.
27. Enter the telephone number of the person completing Section B.
28. Enter the current date.
MAIL COMPLETED FORM TO:
EDD-Paid Family Leave (PFL)
P.O. Box 997017
Sacramento, CA 95799-7017
