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Employment Development Department
Employment Development Department

Paid Family Leave - Manual Forms

Instructions for completing the Claim for Paid Family Leave (PFL) Benefits (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 use.

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

A5. Check the appropriate box for gender: male or female.

A6. Enter your telephone number, area code first.

A7. Enter any other last name you may have worked under.

A8. Enter your mailing address, if you use a post office box, 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 PFL claim to begin.

A12. Date you returned or will return to work.

A13. Check the appropriate box (1) yes or (2) 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
  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
  5. Parent-in-law
  6. Grandparent
  7. Grandchild
  8. Sibling
  9. 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. If your employer(s) continued or will continue to pay you during your family leave, enter 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 Recipient's Authorization for Disclosure of Personal-Health Information – Please carefully review the information provided in this section. It is important to have the care recipient sign both this page and page 3 in item C6 of Part C to keep this claim from being delayed 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, if applicable.

B3. The child named in section B8 is my (define relationship). Please check the appropriate box:

  1. Biological child
  2. Stepchild
  3. Foster child
  4. Other

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

B5. Enter the child’s Social Security number, if available.

B6. Enter the child’s date of birth.

B7. Check the appropriate box for child’s gender: male or female

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

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

B10. As proof 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. Adoptive Placement Agreement AD-907
  6. Child’s passport showing immigration and naturalization service stamp I-551
  7. Independent Adoption Placement Agreement (AD-924)
  8. Other (please explain)

B11. After reading and agreeing with the declaration, provide your signature and the date that you signed the claim. Rubber stamps are not acceptable.

Part C – Statement of Care Recipient (This section may be completed by claimant if care recipient is mentally or physically unable to do so. It must be signed by care recipient or care recipient’s authorized representative.)

C1. Provide the care recipient’s date of birth.

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

C3. Check the appropriate box for the care recipient’s gender: male or female.

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.