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 offical?

Yes

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.