You must have JavaScript enabled to use this form. Select your zip code - Select -900149027490802910069101091008910169120291702917069172291723917249174091741917449174691773917909179191792Other- Select - Contact Information Name First Middle Last Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Phone Number Email Address Date Applied for Claims What did you apply for? - Select -Unemployment Insurance (UI) Pandemic Unemployment Assistance (PUA)State Disability Insurance (SDI)Paid Family Leave (PDL) What is your issue? What is your issue? OtherID verificationWage verificationAppealsUnpaid benefits Pandemic Unemployment Assistance (PUA)Other… Enter other… Have you certified for ALL weeks pending of benefits? Yes No 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 No Who have you contacted? Comment [Optional] Disclaimer: Please do not send any personal identifiable information through this form that is not specifically requested. If we need additional information, such as your EDD number, we will contact you to request that information. Zip code entered is outside of the District. Please use the Find Your Rep webpage to find your District Representatives. Leave this field blank
