Contact Information
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?
Other ID verification Wage verification Appeals Unpaid benefits Pandemic Unemployment Assistance (PUA) Other…
Enter other…
Have you certified for ALL weeks pending of benefits?
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?
Who have you contacted?
Disclaimer: Please do not send personal identifiable information
Please carefully read the following:
By completing this form, I am requesting the Office of Assemblymember Rivas (the “Assemblymember”) to assist me in working with the Employment Development Department (EDD) on my claim. I acknowledge that this may require the release of information contained in my records the dissemination of which may be prohibited by law. Therefore, I hereby authorize EDD and the Assemblymember to share all relevant portions of my records with each other, and to discuss matters relating to those records and my claim, until my claim is resolved.
I agree that I will not submit any personal identifiable information through this form that is not specifically requested. If the Assemblymember’s office needs additional information, such as my EDD number, the office will contact me to request that information.
By clicking here, I accept and agree to the terms in this form.