Paid Family Leave - Manual Forms

The following chart provides instructions on how to complete the Paid Family Leave claim DE 2501F manually:

Instructions on completing the Paid Family Leave claim DE 2501F:

Part A – This section must be completed if you are requesting PFL benefits as either a care or bonding provider.

A1. Enter your social security number.

A2. Enter your date of birth.

A3. Enter the language that you prefer to speak.

A4. Enter your legal name (first name, middle initial and last name)

A5. Check the appropriate box, for female or male.

A6. Enter your telephone number, beginning with the area code first.

A8. Enter your mailing address, if you use a post office box, please place that information in the space marked PMB#.

A9. Enter the name, address and phone number of your employer.

A10. Enter the date that you last worked.

A11. Enter the date you want your Paid Family Leave claim to begin.

A12. Date you returned or will return to work.

A13. Check the appropriate box, yes or no; Did you work or will you continue to work during your family leave period?

A14. Check the appropriate box (1) care for family member (2) bond with child or (3) other and explain: Why did you or will you reduce your work hours or stop working.

A15. Enter your current occupation.

A16. Enter the legal name of the person that you are caring or with whom you are bonding (care or bonding recipient). Enter first name, middle initial and last name.

A17.Check the appropriate box, (1) child, (2) spouse, (3) registered domestic partner, (4) parent or (5) other and explain. The above-named care or bonding recipient is my (define relationship).

A18. Check the appropriate box (1) yes or (2) no. Is any other family member ready, willing, and able and available to provide care for the same period you are claiming PFL benefits?

A19. Check the appropriate box (1) yes or (2) no. Have you claimed or do you plan to claim workers’ compensation benefits for any portion of the period covered by this claim?

A20. Check the appropriate box (1) yes or (2) no. Do you have more than one employer?

A21. Check the appropriate box (1) sick, (2) vacation or (3) other. Please explain if your employer(s) continued or will continue to pay you during your family leave, indicate the type of pay you will receive.

A22. Check the appropriate box (1) yes or (2) no. May we disclose benefit payment information to your employer(s)?

A23. Check the appropriate box (1) yes or (2) no. 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?

A24. After reading the below declaration, please provide your signature in the first box or if signature is made by a mark (X), please place it in the second box. In the third box, please provide the date that you signed this claim. If your signature is made by a mark (X), it must be attested by providing two witnesses signatures and addresses.

Care Recipients Authorization for Disclosure of Personal-Health Information – – Please carefully review the information provided in this section prior to signing. It is important to sign both this page and page 3 in item C6 of Part C to keep this claim from being held up or returned.

Part B – Bonding Certification (To be completed by person claiming PFL benefits to bond with child).

B1. Enter your social security number.

B2. Enter date of foster care or adoption placement.

B3. Please check the appropriate box; (1) biological child, (2) stepchild, (3) foster child, or (4) other. The child named in section B8 is my (define relationship).

B4. Enter claimants (your) legal name (first name, middle initial and last name).

B5. Enter child’s social security number, if available.

B6. Enter child’s date of birth.

B7. Check the appropriate box, (1) female or (2) male. Provide the child’s gender.

B8. Enter the child’s legal name (first name, middle initial and last name).

B9. Enter the child’s residence address if different from claimants.

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). (1) child’s birth certificate, (2) child’s hospital discharge record, (3) declaration of paternity, CS-909, (4) foster care placement record, SOC-815, (5) certificate of placement, AD-907, Child’s passport showing immigration and naturalization service stamp I-551, (6) Independent adoption placement agreement, AD-9After reading the below declaration, please provide your signature and the date that you signed this claim. Rubber stamp is not acceptable.24, or (7) other (please explain).

B11. Enter your social security number.

Part C – Statement of Care Recipient (This section 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. Provide recipient’s date of birth.

C2. Provide recipient’s telephone number, area code first.

C3. Check the appropriate box, (1) female or (2) male. Provide the recipient’s gender.

C4. Enter the care recipient’s legal name (first name, middle initial and last name).

C5. Enter the care recipient’s residence address.

C6. After reading and agreeing to the below Confirmation of Medical Disclosure Authorization, please have the care recipient sign and date this section.

C7. If you are the authorized representative signing on behalf of the care recipient, you must complete this section. Provide required documentation and date and sign this section.