You must have JavaScript enabled to use this form. Contact Information Name First Middle Last Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Phone Number Email Address 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? OtherID verificationWage verificationAppealsUnpaid benefits Pandemic Unemployment Assistance (PUA)Other… Enter other… Have you certified for ALL weeks pending of benefits? Yes No 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? Yes No Who have you contacted? Comment [Optional] 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 Wicks (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. SOLICITUD DE AYUDA Y AUTORIZACIÓN PARA LA DIVULGACIÓN DE INFORMACIÓN Lea atentamente lo siguiente: Al completar este formulario, solicito a la Oficina de la Asambleísta Berman (la "Asambleísta") que me ayude a trabajar con el Departamento de Desarrollo Laboral (EDD por sus siglas en inglés) en mi reclamo. Reconozco que esto puede requerir la divulgación de información contenida en mis registros cual la divulgación puede estar prohibida por ley. Por lo tanto, autorizo a EDD y al Asambleísta a compartir todas las partes relevantes de mis registros y a discutir asuntos relacionados con esos registros y mi reclamo, hasta que se resuelva mi reclamo. Acepto que no enviaré ninguna información de identificación personal a través de este formulario que no se solicite específicamente. Si la oficina del Asambleísta necesita información adicional, como mi número de EDD, la oficina se comunicará conmigo para solicitar esa información. By clicking here, I accept and agree to the terms in this form. /Al hacer clic aquí, acepto los términos de este formulario.