EDD Troubleshooting Request Form

Please watch the video below
before submitting your request for assistance.

Assistance Form
Contact Information
Name
Address
What is your issue?
Have you certified for ALL weeks pending of benefits?
Have you contacted another elected offical?


REQUEST FOR ASSISTANCE AND AUTHORIZATION FOR RELEASE OF INFORMATION

Please carefully read the following:

By completing this form, I am requesting the Office of Assemblymember Maienschein (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.

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