Once you submit this form, our staff will follow-up with you via email or phone call regarding next steps. STEP ONE Verify your Assembly District. You must have JavaScript enabled to use this form. Select your zip code - Select -94505945069450794514945169451894523945269452894546945499455094551945529455394556945639456694568945709457594582945839458694588945959459694597945989461194619947049470594708951409537795391Other Contact Information First Name Last Name Complete Residence Address Address City/Town State/Province - None - ZIP/Postal Code Best Phone to Contact You Email Name of your last employer Last day you worked for your last employer EDD Information Date that your unemployment benefit year began? (e.g. 3/6/20) If your benefit year began over 365 days ago and you are a W2 employee, have you filed a brand new UI claim? Yes No If you did file a new UI claim, on what date did you actually sit down and fill out that new claim filing? What EDD program did you apply for? Unemployment Insurance (UI) Pandemic Unemployment Assistance (PUA) Disability (SDI) Paid Family Leave (PFL) I don't know Other How would you categorize your recent work status? W2 employee Independent Contractor Both What is your issue with your EDD claim? (Please be specific.) Have you certified for ALL benefit weeks available to you for certification? Yes No Unsure System will not allow me What is the last week for which you were actually able to certify for benefits?” (e.g., week ending April 4) What is the last benefit week for which you actually received payment? (e.g. week ending March 6) What is the “Claim Balance” in dollars remaining on your claim? List any correspondence, if any, you have received from EDD via mail/text/email. Example, Letter with Notice of Determination Have you contacted another elected official about this issue? Yes No If yes, who have you contacted? Additional Comments: 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. I Agree Leave this field blank