You must have JavaScript enabled to use this form. Select your zip code - Select -9260392604926069261292614926179261892625926269262792629926379264692648926519265392656926579266092661926629266392677927049270792782Other 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 Unsure 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 offical? Yes No Who have you contacted? Comment [Optional] Disclaimer: 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. REQUEST FOR ASSISTANCE AND AUTHORIZATION FOR RELEASE OF INFORMATION. By completing this form, I am requesting the Office of Assemblymember Petrie-Norris (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. Zip code entered is outside of the District. Please use the Find Your Rep webpage to find your District Representatives. Leave this field blank